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1917 5 O O"
1918 47 4 8.3
Prior to taking the office of health officer, my
predecessor, Dr. A. H. Allen, called my attention to
the prevalence of diphtheria in the city. Upon as-
suming office all the diphtheria cases for the years
1918 and 1919 were spotted on a large map of the
city, and although it was not confined to one sec-
tion, the majority of the cases seemed to centre
about one school. At the same time a study was
made with reference to the diff'erent milk routes in
the citv, but this did not establish any connection
between milk and disease. It was assumed, there-
850
BREWER: DIPHTHERIA EPIDEMIC.
[New York
Medical Journal.
fore, that- the problem was one of carriers, and
the campaign was based upon that assumption.
Cultures were taken immediately from all the
pupils and the teachers in the school where the
largest number of cases had occurred. This netted
twenty-three carriers, and immediately the number
of new cases in that vicinity was cut down. Later
in the season a case occurred in a children's home
where there were eighty residents. Cultures from
those children revealed twenty-two carriers. La;r;r
in the summer several cases were reported in a
short street, and after a study of the cases a num-
ber of cultures were taken, resulting in the dis-
covery of several carriers. Early in the fall a num-
ber of cases appeared in another street, and cultures
taken from the children disclosed six carriers.
Shortly after the opening of school in the fall three
cases were reported from one room, and cultures
taken revealed twelve carriers. We also adopted
the plan of culturing all members of the family,
and a number of carriers were picked up in that
way. In all 105 carriers were discovered. Thai
many of them were but transient carriers is obvi-
ous, but we believed then, and still believe, that
most of them were sources from which other cases
would have developed.
\'irulence tests were made in a number of these
cases, but the number was too small to be reported.
During September a child became ill with what was
called enteritis, but as there was no improvement
under the usual treatment a more careful study
was made, when it was found that the child had
an extremely sore throat which clinically was diag-
nosed as diphtheria. The child was so sick that
cultures were not made, but a large dose of anti-
toxin was immediately given. On receiving the re-
port of the case cultures were taken from the rest
of the family, including a relative who had recently
arrived and who had a slight nasal catarrh. Three
out of five cultures taken in this group were posi-
tive, but virulence tests were negative, and these
persons were immediately released from quarantine.
That the laboratory diagnosis was reliable is demon-
strated by the fact that no new cases occurred in
that vicinity or among the friends or associates of
these persons.
We did not expect to eliminate the carrier from
the community, but we did hope to find a large
number of them, and by so doing to control the
disease. During the year 1919 we took 3,092 cul-
tures, and a considerable number were taken by
the Buy Angeliq physicians of the city and examined at a local
laboratory, which were not included in the number
given. The taking of so many cultures was quite
a tax upon the force of the department.
The diphtheria carrier was a new thing to many
of the citizens, and they could not miderstand at
first the reason for isolating a person who was ap-
parently well. To overcome this we started,
through the cooperation of the editors of the Times
and the Standard, a campaign of education, the re-
sult being that when the last batch of carriers was
discovered there was practically no opposition to the
necessary isolation.
The happy termination of the campaign is largely
due to the splendid cooperation with the physicians
of the city. They were prompt in reporting their
cases, and many of them made cultures on many
sore throats which did not appear to be diph-
theritic. Personally I have felt for a long time
that in a large number of cases, inflammation of
the throat, especially that which is called tonsillitis,
is really diphtheria. A case which illustrates this
came under my observation recently. Upon look-
ing into the child's throat one tonsil was seen to
be covered with membrane, having all the appear-
ance of tonsillitis. It was easily wiped off, but cul-
tures showed the diphtheria bacillus, and it was
a long time before we were able to get a negative
culture. A physician who saw the patient on the
day the result of the culture was reported said that
he was sure it was nothing but tonsillitis.
Treatment. — Antitoxin was used freely by the
local physicians, and as a rule was administered
early. Its use as a prophylactic was general. In
most of the fatal cases the patients were seen late
in the course of the disease or died from complica-
tions. In the treatment of carriers the removal of
the tonsils is the most satisfactory procedure, pro-
vided they are enlarged or contain diseased follicles.
Time and time again we have seen a case which
had resisted all known local treatment rapidly clear
up after the removal of the tonsils. In cases where
the tonsils were not diseased some physicians were
successful with the use of dichloramine-T, others
found ten per cent, nitrate of silver equally eft'ec-
tive, while others used chlorazene with good results.
Toward the end of the epidemic we were able to
do the Schick test on a large number of children in
an institution. Many of these children had received
an immunizing dose of antitoxin about six months
previously. The result of this study will be reported
later. It was not found practical to try the Schick
test on other children.
Statistics of the disease. — During the first week
of 1918 one case was reported. The next case was
recorded during the week ending March 4th. Xo
cases were reported Angeliq Hrt until the week ending April
30th, when two were reported. New cases con-
tinued to be reported each week until the week
of June nth, when the number fell to zero. An
interval of two weeks occurred without a case, after
which there was an interval of four weeks without
a case. During the week of August 14th there were

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