was a formidable undertaking, with our limited corps of nurses, but seemed essential to successful control of quarantine, and the result confirmed this opinion. The reasons are obvious: after a patient has recovered, he is naturally anxious to be freed from restrictions. Pressure is brought to bear upon the physician who, without compensation, is called upon to make visits for the purpose of securing cultures. One or two gratuitous visits may be made cheerfully, if he is in sympathy with health activities. But if diphtheria bacilli continue to make their appearance, in the present state of public education the physician becomes unpopular and he is scarcely human if he is not strongly tempted to follow a procedure which will insure a negative culture report. The following figures taken recently from our quarantine records, are interesting in this connection: during a period of about three months, prior to April 1, 30 cases had had positive cultures for three weeks, 23 for four weeks, 13 for five weeks, four for six weeks, seven for seven weeks, two for eight weeks, and one for nine weeks. In consideration of the foregoing, the writer is confirmed in his personal belief that, both out of consideration of the physician and in the interest of effective quarantine, the responsibility for the taking of release cultures should invariably rest upon the health authorities. The dates upon which release cultures were taken, both upon cases and carriers, were recorded from day to day upon charts arranged with parallel columns, and reports upon them were recorded as they were received. Reports were also recorded alphabetically in a loose leaf book. This constituted the most important duty of a special clerk. In view of the difficulty. even with this system, of avoiding errors, it was evident that the control of releases with reports received by telephone and unrecorded, was, to say the least, uncertain. To control the exclusion from school of children with sore throats, it was ultimately arranged that children apparently ill would be excluded immediately and reported for investigation, while the others would remain in school to be examined by one of the school physicians, who visited each school daily. This system avoided a large number of unnecessary exclusions and was highly effective, but consumed practically the entire time of the school physicians and nurses during several weeks. The culturing of the throats of school children was carried out by the school staff, with the writer's assistance. The schools in which the largest number of cases had occurred were visited first. All throats were examined, cultures being made from those showing redness beyond normal, or where there was a known history of sore throat or contact. In this locality congested throats and catarrhal conditions were unusually prevalent, and the increased susceptibility to throat disorders without doubt added to the difficulty of controlling the disease. After visits had been made to all of the schools, we devoted our attention to those in which cases still occurred. According to circumstances we either re-examined and cultured entire schools, or went into grades and cultured contacts. Up to the time of writing, approximately 249 school carriers had been discovered and isolated, a number having been previously released cases. It frequently happened that two or more children in a family, all in different grades, were found to be carriers. In one such family there were three carriers, all of whom were still positive and virulent at the end of twelve weeks. In this connection, in every instance in which virulence tests were made upon school carriers, the organisms were found to be virulent. In the schools in which there had been the largest number of cases, there was an immediate and marked decline following the exclusion of the carriers. The exclusion from school and isolation of a large number of children, unfortunately at a time when examinations were pending, created a difficult situation, not less difficult from the fact that germ carriers were an innovation. Parents of persistent carriers were urged to consult their family physicians and a limited number acted on this advice. In some instances this resulted in active local treatment being instituted. In others, physicians were quoted as advising parents that treatment and isolation were unnecessary, and when a simple gargle proved ineffective, nothing further was done. Later one of the city physicians volunteered to give local treatments to a number of such carriers. On April 23 there still remained a group in which, in spite of such treatment, the carrier condition had persisted for from two to three months, and where removal of tonsils had been refused. The following illustrates concretely the possibilities of spread of infection through carriers, in this instance an adult: Four or five cases had occurred during a period of two or three months in one of the railroad offices. In December a child of a clerk in this office developed diphtheria. Several weeks after the discharge of this case, a second child in the same family developed the disease. At this time a culture was secured from the father, and it was learned that about four months before he had had a sore throat. The doctor had suspected diplitheria, had sent a swab to the local laboratory, received a negative report, and changed his diagnosis. Pending a report on the culture, the father, in order to continue at work, moved to the home of an adult brother, who developed diphtheria a few days later. The culture proved this man still to be carrying diphtheria organisms, which promptly disappeared following tonsillectomy. Another instance emphasizes the importance of culturing, by physicians, of suspicious throats, and by health departments, of contacts. A physician without making a culture diagnosed a case as tonsilitis. He telephoned the Health Department, however, suggesting that a nurse call. Cultures taken by the nurse demonstrated that six members of the family were diphtheria carriers. The case incidence from early December, at which time our campaign was begun, has been interesting. Twenty-three cases were reported in a week immediately following our meeting of physicians. During the holiday vacation the cases dropped to ten in a week and rose again to 22 shortly after the reopening of the schools. From that time on, during a period of eleven weeks in which our activities were continued without remission, in spite of unfavorable weather conditions there was a gradual decline, until in the week ending March 22, but three cases were reported. At this time it was felt that the Sanitary Supervisor was more seriously needed in other parts of his district; the school physicians and nurses began to take up their routine work and one of the State's supervising nurses and a clerk |