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picture, notably those which have occurred in some of the wars of the past century; but the medical profession must learn to recognize that bacillary dysentery may present itself as a mild disturbance of the gastrointestinal tract. In this series of cases the diagnosis of bacillary dysentery was made in 315 of a total of 494 cases of intestinal disturbance. The diagnosis was determined in one of three ways: (1) positive bacteriological findings, (2) clinical picture and (3) epidemiological evidence. It is probable that a large number of the remaining 179 cases of diarrhea were bacillary dysentery, but according to the above classification éould not be included as such. Analyzing the symptoms of the total number of cases, sudden onset was found in 203, gradual in 20, and history of onset lacking in 92. There was initial chill in 60 and convulsion in 1; 135 suffered with fever, 96 with headache, 114 with nausea and 112 vomited. Abdominal pain was present in 178 cases, pain in the back in 1. Four were constipated at the onset; 311 had diarrhea; 112 passed blood and 73 passed mucus. The duration of illness varied from one day to seven weeks, as shown in the following table:

Duration of Illness

Cases * Duration Cases Duration 14. . . . . . . . . . . . . . . . . . . . . . . 1 day 12. . . . . . . . . . . . . . . . . . . . . 2 weeks 24. . . . . . . . . . . . . . . . . . . . . . . 2 days 4. . . . . . . . . . . . . . . . . . . . . 3 weeks 22. . . . . . . . . . . . . . . . . . . . . . . 3 days 2. . . . . . . . . . . . . . . . . . . . . 4 weeks 14. . . . . . . . . . . . . . . . . . . . . . . 4 days 1. . . . . . . . . . . . . . . . . . . . . 5 weeks 13. . . . . . . . . . . . . . . . . . . . . . . 5 days 1. . . . . . . . . . . . . . . . . . . . . 6 weeks 6. . . . . . . . . . . . . . . . . . . . . . . 6 days 1. . . . . . . . . . . . . . . . . . . . . 7 weeks 24. . . . . . . . . . . . . . . . . . . . . . . 7 days 177 . . . . . . . . . . . . . . . . . . . . . unknown Age Incidence Under one year. . . . . . . . . . . . . 22 30–40 years. . . . . . . . . . . . . . . . . 29 1–5 years. . . . . . . . . . . . . . . . . . . 99 40–50 years. . . . . . . . . . . . . . . . . 10 5–10 years. . . . . . . . . . . . . . . . . . 21 50–60 years. . . . . . . . . . . . . . . . . 24 10–20 years. . . . . . . . . . . . . . . . . 24 Over 60 years. . . . . . . . . . . . . . . 24. 20–30 years. . . . . . . . . . . . . . . . . 45 Unknown . . . . . . . . . . . . . . . . . . . 8

The conditions giving rise to the epidemic are numerous. (1) Bacillary dysentery has been endemic in this community for at least feur years. We have records of 28 cases which occurred between November 1, 1916, and June 1, 1917. (2) Insanitary conditions of sewage disposal and other conditions which favored fly breeding. (3) Personal contact either in the street, at home, or at place of employment. (4) Mild cases which did not seek medical advice and hence received no instructions as to precautionary measures to be taken. This last factor was perhaps the greatest menace.

The disease occurred on 72 streets of the city, on 39 of which there were cases of bacillary dysentery in 1916. Analysis of the streets involved shows that 11.1 per cent of the streets contained 36.8 per cent of the cases. There were 199 houses invaded, of which 131 had single cases while 68 had more than one case as shown in the following table:

Total Total Houses Cases Cases Houses Cases Cases 38 $2 76 l 5 5 IS 3 54 l 6 6 9 4 36 l 7 7 6S 1S4 34.4% 58.4%

In nineteen instances there were cases of bacillary dysentery in the same house in 1916. Thirty-two of the patients gave a history of previous attacks of dysentery. Maps were made showing the location of privies, unprotected garbage and One on which were spotted the cases of dysentery (see following page), very definite conclusions could be drawn as to the relationship between the cases and the fly. This view was confirmed by the fact that the case incidence dropped very quickly when the hot weather moderated and the flies became less active. None of the privies found were sanitary; screens were conspicuous by their nonexistence. That personal contact was a large factor in the spread of the disease can be seen from the table above showing that 34.4 per cent of the houses contained 58.4 per cent of the cases. In addition we found that many of the cases could be grouped according to place of occupation. Four cases were employed in factory “A”; 4 were employed in factory “B” and in addition the father of another case; 5 cases were employed in factory “C” and in addition the fathers of 3 others; 2 cases worked in factory “D,” 5 in “E,” 2 in “F,” 5 in “G” and 2 in “H.” The food supply was investigated in all cases, but in no case could any number of patients be found who had bought food in any one particular establishment. A strange feature of this part of the investigation was that in one instance a case of chronic bacillary dysentery was found in a woman who owned a small grocery store, but no cases developed among those who had bought food in this store. In another instance two cases occurred simultaneously in a family living some distance from the epidemic center. Upon investigation it was found that the family had eaten bread purchased in a dirty bakery located only a short distance from Several privies adjoining houses in which there were cases of bacillary dysentery. This bakery was infested with flies and all foodstuffs were uncovered; therefore it was very probable that flies had contaminated the bread. The milk used by the various cases of dysentery was found to have been supplied fairly equally by all of the fourteen dealers of the city. That the water supply was not responsible was quite evident from the fact that all of the early cases were in one section of the city. In addition, a study of the bacteriological reports of the daily water examinations absolutely excluded the water as a source of infection. Control of the epidemic was a difficult problem. From the very beginning it was recognized that there were large numbers of missed cases, and prompt search for such cases was begun. The local health board passed a regulation calling for the prompt reporting of all cases of diarrhea. A house to house canvass was made in the western part of the city and in this way 168 cases of bacillary dysentery were discovered. Strict isolation and quarantine were deemed impracticable since it would then have been impossible to search out the mild eases. It was thought to be of greater value to find these cases and to instruct them in precautionary measures.

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Three local nurses were used exclusively for intensive follow-up work. As soon as a case of diarrhea was discovered it was investigated to determine whether it was bacillary dysentery or simple diarrhea. Instructions as to screening, cleanliness, disinfection of discharges, etc., were given. If the case were bacillary dysentery the patient was visited by one of the nurses whose duty it was to see that the instructions given were properly executed. In nearly all cases observation was continued until at least two examinations of stools, at least twenty-four hours apart, were negative.

Hospitalization was carried out in so far as possible, but owing to the Iarge number of cases and lack of hospital facilities this could only be accomplished with an insignificant number.

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Preventive inoculations with a toxin-antitoxin mixture and with polyvalent dysentery vaccine were given to contacts, wherever their consent could be secured. As comprehensive a list of contacts as possible was obtained in all cases. The total number of contacts listed was 995; of these 834 received no immunizing treatment and subsequently 109 or 11.9 per cent developed dysentery. Of the remainder 161 received immunization

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and only 4 or 2.5 per cent subsequently developed the disease (53 received toxin-antitoxin mixture, and 4 or 7.5 per cent developed dysentery; 108 received polyvalent dysentery vaccine

infected). Treatment of the actual cases varied. severe cases, a few of the local physicians used the polyvalent antidysentery

serum made in the laboratory of the State Department of Health.

results were excellent. The dose recommended at first was 20 c.c., but experience showed that this was inadequate as the best results were obtained by the

and none subsequently became

For the treatment of the more

us of at least 50 c.c. or more. This was repeated every twenty-four hours if necessary (usually two or three such doses were sufficient). In one case the serum was used intravenously with almost miraculous result. Frequently following the use of the serum blood promptly disappeared from the stooks and the frequency of bowel movements was reduced from 50 or 60 per day to 20 or less. In one instance there was a reduction in frequency from 60 to 4 movements per day within the 24 hours following the use of the SęTUICl. The fatality rate, 4.1 per 100 cases, is low, especially when compared with the fatality rate in the epidemic of 1916, 21.6. This was due in part to the fact that the Shiga type of organism, which is the most toxic type, occurred less frequently, and also may be due in part to the more common use of antidysentery serum in large dosage. The principal condition which prevented prompt control of the epidemic was the fact that from ten days to two weeks elapsed after the onset of the disease in an individual, before that case came to the attention of the health authorities. The chart (page 134) shows this elapsed time.

Conclusions

I Bacillary dysentery presents itself as a variable symptom complex. All cases of intestinal disturbance associated with diarrhea, should be treated as cases of bacillary dysentery in so far as measures to protect the health of the community are concerned. y

2 Reporting all cases of diarrhea to the health department, is a measure to be recommended.

3 Polyvalent dysentery vaccine should be used in all cases of contact with an established case of bacillary dysentery.

4 Polyvalent antidysentery serum should be used in large doses, at least 50 c. c. in the treatment of severe cases of bacillary dysentery.

5 Sanitary conditions must prevail in order to prevent bacillary dysentery from assuming epidemic proportions once it is introduced into a community.

During and following the Poughkeepsie outbreak numerous cases were discovered in nearby municipalities and vigorous action was taken by state and local health officials to prevent further spread of the disease.

Two smaller outbreaks, worthy of special comment, occurred during the late summer and early fall.

During September, Dr. C. R. Hervey, Sanitary Supervisor, investigated an outbreak of 12 cases which occurred in the towns of Walworth, Williamson and Ontario, Wayne county. The striking features regarding this outbreak were that at the time of investigation two members of the first family to be infected had died and a third was regarded as moribund, and that subsequent cases were traceable to contact with members of this first family. Apparently none of the cases were confirmed bacteriologically.

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