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difficulty lay in the fact that the school had been closed as a means of preventing further spread of the disease. Seventeen carriers were found among those who attended in response to the announcement that attendance was desired for that purpose and among these were several who had had clinical diphtheria or were members of families in which clinical cases had existed. These findings led to the reculturing of all cases that had previously been released and to the adoption by the local board of health of a rule requiring that negative cultures should be obtained from all members of quarantined families prior to release and that release cultures should be taken by a representative of the board. Vage earners were isolated until one negative culture was obtained followed by a second culture taken after removal from the quarantined premises.

The outbreak continued into 1918 but with the important difference that the cases no longer prevailed chiefly among school children in fact but 3 or 4 cases occurred among them in January and February. Incidentally, one of the discovered school carriers explained satisfactorily a number of cases not explicable by school contact. This boy aided one of the milk dealers in the distribution of his supply, ran many errands, sold papers and was generally industrious and ubiquitous. The school cultures also brought to light one or two carriers who had had clinical diphtheria but had shown negative cultures at the time of their illness. These cases, with some exceptions, had not been isolated and constituted additional sources of infection. It was learned that a considerable number of such cases had existed in October and November and were regarded, because of the severity of the symptoms and the absence of diphtheria organisms, as cases of septic sore throat or serere tonsilitis.

A partial explanation of these negative cultures was found in the difficulty of maintaining an even and proper temperature in the incubator at the laboratory owing to the thermostat having been out of order for an unknown period of time. There were also some well marked clinical cases giving negative throat but positive nasal cultures, the throat cultures showing staphylococci. Cultures of Hoffmanii were very numerous among contacts and school children cultured, from 20 to 30 per cent showing them among the children attending the second school cultured.

The similarity of the Binghamton and Gloversville outbreaks to other outbreaks investigated elsewhere, leads to the belief that the appearance of any unusual number of cases in a community should promptly lead to the adoption of more stringent methods. of control than are provided in the rules of this department. The most important measures are the culturing of all members of a household prior to raising quarantine and the culturing of suspicious prior contacts for the purpose of discovering the carrier or missed case responsible for transmitting the infection. Culturing intimate subsequent contacts outside the household will sometimes lead to the discovery of an incipent case or carrier though this procedure is not always worth the difficulties encountered in obtaining the cultures. A rule requiring that release cultures shall be taken by a representative of the local Board of Health is usually advisable and sometimes necessary. It saves the attending physician many unrequited visits, saves him from the responsibility of maintaining the quarantine and in some instances prevents the submission of improperly taken cultures.

The groups of smaller cities of the State show case fatality rates ranging from 6.3 to 7.3 per cent, indicative of more prompt diagnosis and treatment and possibly of lower virulence and more complete case reporting than in the larger cities. The so-called rural section of the State, which however, includes all the villages. with three exceptions, had a case fatality rate of 9.5 per cent. A further analysis of the figures for this group is suggested by this to determine to what extent it is due to delayed diagnosis and treatment. The difficulty of winter travel in the “truly rural” districts may be the determining factor in raising the rate for the group. The death rate is the lowest in the state. In fact the death rate throughout the groups grows progressively smaller as the units decrease in population — the first class cities having the highest, the “rural " districts the lowest.

districts the lowest. While perhaps little can be done by health departments to better many of the conditions incident to urban life yet varying rates of the cities within a given class show that much can be done to lessen the incidence of infection. Congested street cars and crowded movies do not cause diphtheria but simply provide excellent points for the

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Chart 7



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