370 TYPHOID FEVER 



tion of food. From time to time, however, larger epidemics 

 have arisen from a carrier having contaminated a milk supply in 

 a dairy. The site of the multiplication of the bacteria in a great 

 many of these carriers is probably the gall-bladder (see p. 364). 

 As has been stated, the typhoid bacilli may persist there for 

 many years, often giving rise to gallstones. The fact that women 

 appear to be more liable to gallstones than men constitutes 

 a serious factor in relation to the problem of the typhoid carrier, 

 as women are more concerned in the preparation of food. An 

 additional danger lies in the fact that carriers usually appear to 

 be in perfect health or may only suffer from slight, and to them 

 unimportant, pains in the region of the gall-bladder, it being 

 well known that in only a proportion of patients suffering from 

 gallstones do severe symptoms arise. An additional factor in 

 the carrier problem lies in the fact stated above, that apparently 

 certain persons ingest the typhoid bacilli, and the latter may 

 multiply for some months in the intestinal tract without giving 

 rise to typhoid fever. Such persons have been referred to as 

 " paradoxical " carriers ; they represent those who either are 

 naturally insusceptible to typhoid fever or who have developed 

 immunity in consequence of a previous attack ; they may con- 

 stitute a danger to susceptible persons with whom they may 

 come in contact. The most serious danger to a community 

 arises, however, from the " chronic " carrier. In certain carriers, 

 the focus of multiplication of the typhoid bacillus may not be 

 the bowel but the kidney or bladder, the bacilli in such cases 

 passing out in the urine. 



The tracking down of 'a typhoid carrier constitutes an impor- 

 tant and difficult problem. Firstly, the serum of all suspicious 

 persons ought to be subjected to the Widal test (vide infra). 

 Usually speaking the carrier gives a positive reaction, but 

 sometimes this is absent and sometimes is only obtained with a 

 low dilution of the serum. Further, it has been shown in 

 chronic carriers that the agglutinating capacity of the serum 

 varies from time to time and sometimes may be absent. The 

 proof of the presence of a carrier lies essentially in the isolation 

 of the typhoid bacillus from the faeces or the urine, and it is to 

 be noted that, especially in the former, the organism is not 

 constantly present, in certain cases months of remission have 

 been recorded. This of course may be due to the difficulties of 

 the search, but whatever the explanation, it necessitates repeated 

 examinations. Much work has been directed to the question of 

 freeing the typhoid carrier from the organism, but although 

 various methods, such as intestinal antisepsis, vaccination, 



