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The fact of a negative report having been received upon a fecar specimen from one case is possibly accounted for by delay in transmission through the mail to the laboratory at Albany. Dr. Hervey described the clinical picture in one typical case as follows: sudden onset; elevation of temperature for about five days to approximately 102,” with marked weakness following subsidence of fever, abdominal tenderness; ten to twenty bowel movements, with blood and mucus, daily, increasing in number to twenty or thirty, the movements later becoming putrid in odor and resembling “meat water”. During August and September there occurred in the village of Deposit and vicinity an outbreak in which 57 cases were discovered and with 7 deaths. Forty-eight cases were reported from the village, 3 from the town of Deposit and 6 from the town of Sanford. The outbreak was investigated by Dr. Laidlaw and Dr. Conway, Sanitary Supervisors of the two districts involved, assisted by Dr. Godfrey, Epidemiologist. Cases occurred in various age and sex groups as follows:

[graphic]

AGE Males Females Total

Under 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 5. *...* * * * * * * * * g e o os e e < * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 3 5 8. 10-14. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 2 6, 15-29. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 7 12: 30–49. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 8 10. 50 or over. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 4. S. Unstated. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 6 8. Total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 34 57

The chart No. 3 shows the incidence of cases by weeks, according to dates of onset. It will be noted that the greater number of onsets fell within the week from August 22 to 28.

From the fact that the cases were distributed over a wide area, including the county outside of the village, and had nothing in common except that practically all had used the village water to: some extent, the water supply was regarded with suspicion.

Neither inspection nor analysis (bacterial count being low and no colon bacilli being present in 1 c.c. samples) confirmed this suspicion. If water is excluded as a source of infection, it must be assumed that contact, and to a less extent, flies, were responsible

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Diphtheria

During the year 19,183 cases of diphtheria were reported in the state, 12,624 of these from New York City and 6,559 from the rest of the state. In the state, as a whole, 1,745 deaths occurred. (For detailed analysis of diphtheria statistics for the year, see special report, page 141.) Except for Albany County, which had a case rate of 737 per 100,000 population, the highest case rate was maintained in Broome County with 550. This excessive rate was chiefly accounted for by an outbreak which occurred during the winter in the city of Binghamton.

A summarized account of this outbreak prepared by the writer, then sanitary supervisor, for presentation at the annual meeting of the New York State Medical Society, follows:

AN ouTBREAK OF DIPHTHERIA IN A SECOND CLASS CITY

Late in November, 1916, the attention of the officials of a second class city, having a population of about 54,000, was called to the fact that diphtheria. Had become so prevalent that the municipality was charged with the highest case rate for this disease of any city in the State. Following a request for assistance from local officials, the writer was assigned to assist in efforts to control the disease. The outbreak was not of the rapidly developing type which, as a rule, yields readily to the application of scientific preventive measures, but one which had been developing progressively for four years and had become generally disseminated. The records indicated that, during 1912, but 28 cases had been reported; in 1913 there were 60; in 1914, 143; in 1915, 201; and finally, in 1916, there were 358, with the greatest incidence in the last three months of the year. Nearly a year before, the attention of local health officials had been called to the fact that the disease was largely localized in one city ward. During 1916 it had invaded nearly all parts of the city. Through the medium of the press the public had been advised of the intended action of the Board of Health, namely, to publish the name of every barn owner in the grade to which his score entitles him. Class A, (75 or over) excellent, Class B, (65–75) good, Class C, (50–65) fair, Class D, unhygienic. Cleanliness alone will place an owner in A, B, or C and any One maintaining a stable which falls below these classes is devoid of consideration, for the welfare of himself or his neighbors, is a menace to the community and should be summarily dealt with. In the clean-up campaigns, a system of scoring also tends to stimulate interest and affords to the property owner a definite idea of what is required in the movement for municipal cleanliness and beautification. From a preliminary survey, we made the following deductions: Generally speaking, 79.5 per cent of the cases had occurred among persons under 20 years of age, the greater number localized to some extent in districts covered by a few public schools. A detailed study of cases in one or two such districts showed that a majority of the cases were among school children, while in a number of other families with cases under or over school age, there were school children, many of whom had had sore throats. There had been continuously occurring cases of “Sore throat ' and “ tonsilitis,” so-called, to some of which no physician had been called. Laboratory work for the city was done under contract by a local firm. Swabs were supplied to the physicians, and, from these, culture tubes were inoculated at the laboratory. Most of the culture material submitted had come from a very few of the 70 or more general practitioners in the city. Release from quarantine, as elsewhere, depended upon the Securing of two successive negative cultures. Swabs were made by the attending physicians, and reports, both positive and negative, returned as a rule after twelve hours’ incubation. There were practically no records of culture examinations, but, so far as could be learned, rarely if ever had a case been kept in quarantine more than two weeks from the date upon which the first release culture had been taken. There was no culturing of contacts. Broad interpretation of the quarantine regulations of the Sanitary Code, due in some part to difficulty of securing adequate financial relief for quarantined persons, together with lack of method and facility for following up quarantine, rendered it more or less ineffective. Terminal fumigation was relied upon for disinfection. There were hospital facilities for twelve cases of all communicable diseases, other than smallpox. There were approximately 7,000 children attending the public schools, with some 1,200 additional in three parochial schools. In the public schools a well organized department of physical welfare, with a small staff of physicians and nurses, was working practically independently, except that cases of communicable disease were reported and a representative visited the Health Department daily, examining the files of report cards received from physicians. Following the survey, our first procedure was to arrange a meeting of local physicians with city and school officials. The situation was presented, regulations reviewed, culture material and report cards distributed, and the plan of campaign outlined. Immediately following this meeting there was a marked increase in the number of cases reported and cultures submitted to the laboratory. The plan of campaign included the culturing of school children and contacts, control of carriers, close supervision and enforcement of rational quarantine, hospitalization where necessary, the seeking out of unreported cases, and the opening up of various channels of communication between the schools and the Health Department. Our plans were carried out as fully and effectively as local conditions and a limited corps of workers permitted. It soon became necessary for the city to provide additional hospital facilities, the result being permanent provision for at least 30 patients. The local laboratory facilities were found inadequate to meet the increased demand and it was necessary at times to send from one to two hundred cultures daily to the State laboratory at Albany. A rule was promulgated providing that cultures for release from quarantine should be taken by the attending physician in any case if he so desired, until one negative culture had been obtained, after which subsequent cultures would be taken by a representative of the Health Department. This

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