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the milk, as at the farms, but also is exposed to chances of becoming 
contaminated indirectly by flies, dust, etc. In some American cities 
many of the diaries are located in the most unhygienic sections, 
and frequently cases of typhoid fever are cared for in houses 
adjoining the dairy or even in the same building, but on the 
floor above. In these instances it is easy to understand how flies may 
pass from the dejecta of a patient to a can or bottle of milk and so be 
the means of conveying the infection. Cans or bottles returned from 
houses in which there are typhoid patients and which have been 
handled by persons caring for the sick and not disinfected before be- 
ing refilled may be the means of disseminating the infection in the 
milk. 
From the water used for washing the bottles or cans, etc., at the city 
dairy, the B. typhosus may reach the milk. Considering the immense 
dilution in which the typhoid bacillus must usually exist in water ta- 
ken from a large volume such as a river or lake for supplying a city, 
it may be that persons are rarely infected directly by the organism in 
the water ; but it can be understood how the occasional B. typhosus in 
the water upon being introduced into the milk and there multiplying, 
may infect persons drinking that milk. 
At the grocery . — In the studies of Rosenau, Lumsden, and Ivastle 0 
on the prevalence of typhoid fever in the District of Columbia there 
were found a number of instances in which the typhoid patients were 
being cared for in a room above or to the rear of the small grocery 
stores. In these stores milk was sold in small quantities, often as lit- 
tle as a cent’s worth at a time, so that a quart bottle would be divided 
among several customers. The same hands that nursed the patient 
purveyed the milk. In such instances not only is there a likelihood 
of infection being sent out in the milk directly from the store, but 
these much-handled bottles may do damage when returned to the 
dairy. 
At the home . — Milk after being delivered to the house may become 
contaminated by the hands of those caring for the sick or by flies, etc., 
and be the medium of conveyance of infection to other members of 
the household. 
DETERMINATION OF AN OUTBREAK OF TYPHOID FEVER DUE TO 
INFECTED MILK. 
In the epidemiological studies of typhoid fever in a city a card 
should be kept for each milk dealer and on this card should be noted 
all cases of typhoid fever in persons who within thirty days prior to 
the onset of illness have used milk supplied by that dealer. Thus, as 
“Hygienic Laboratory Bulletin No. 35, Report on the Origin and Prevalence 
of Typhoid Fever in the District of Columbia, 1907. 
