TO BE FILED OUT BY ATTENDING PHYSICIAN.

Is this the first culture from this case?.........Date..........

Name of Attending Physician...................

Was any antiseptic used on the membrane.........

Clinical diagnosis and remarks:

Date...

First.

Second. Third. Fourth. Fifth.

Sixth. Seventh.

Eighth.

An

The outfit is then returned to the police station. officer is detailed every afternoon to bring the inoculated cultures to the laboratory and to exchange them for fresh ones. The outfits thus brought in are placed in an incubator, which is kept at the temperature of the human body, and there remain until the next morning. At that time some of the growth, which has taken place on the media, is carefully removed to an ordinary glass slide, and after drying is stained and examined under the microscope, in the usual manner.

The slide is numbered and labelled with the result of the examination, and the same number and result is in dicated on the accompanying little book in its proper place. After a report-card corresponding to the result of the examination has been filled out, countersigned and mailed to the physician attending the case and a report of the examination sent to the Chief Medical Inspector, the slides and little books are filed away. The former according to the number of the case and the latter alphabetically, according to the patient's name.

It is urgently requested that cultures be made from the throats of all persons, especially children, who have come in contact with the above case. B. MEADE BOLTON, M. D.,

Director of the Laboratory.

Per..........

¦BUREAU OF HEALTH-LABORATORY OF HYGIENE. LABORATORY No.........

DEAR DOCTOR :-The examination of the culture made from the throat ot.............. does not show the presence of diphtheria bacilli.

.on.......

The case is not true diphtheria, provided the culture was made before the commencement of convalescence. The bacilli often disappear from the throat after convalescence is established. If you desire to make other cultures we will examine them.

B. MEADE BOLTON, M. D.,
Director of the Laboratory.

Per.........

BUREAU OF HEALTH-LABORATORY OF HYGIENE. LABORATORY No.........

Philadelphia,..........

DEAR DOCTOR :-The examination of the............

culture made from the throat of..........

.........189

..on

..........still shows the presence of diphtheria bacilli. The case is therefore not ready for disinfection, but needs further culture

tests.

B. MEADE BOLTON, M. D.,

Per..........

Director of the Laboratory.

BUREAU OF HEALTH-LABORATORY OF HYGIENE.

LABORATORY No.........

Philadelphia,..................................... ........189

DEAR DOCTOR :-The examination of the.............

culture made from the throat of........

..........on

.............................does not show the presence of diphtheria bacilli. The case is therefore ready for disinfection if other circumstances allow. B. MEADE BOLTON, M. D.,

Per........

Director of the Laboratory.

BUREAU OF HEALTH-LABORATORY OF HYGIENE. LABORATORY No.........

DEAR DOCTOR :-The examination of the culture made from the throat of..............

.........on

.....does not admit of an exact bacteriological diagnosis for one or more of the following reasons, as indicated by the pointer:

A. The inoculation was made at a period so late in the disease that it is possible that the diphtheria baccilli were present at an earlier time, although now absent.

B. The growth on the culture media was so scanty that it is probable that the inoculation was not properly made or that some antiseptic had been applied to the throat shortly before obtaining the material for inoculating the tube.

C. The culture was badly contaminated.

D. The serum in the tube was too dry for the growth of the diphtheria bacilli.

a. Another culture is requested.

b. The case should be regarded as probably one of diphtheria.

c. The case should be regarded as probably one of false diphtheria. B. MEADE BOLTON, M. D.,

Per.........

Director of the Laboratory.

The advantages of this system are as follows:

The use of inexpensive paste-board boxes which are used

but once and then destroyed.

The use of aluminum wires for the swabs, as they can be kept bright and clean with dilute sulphuric acid.

The very valuable and efficient co-operation of the Bureau of Police.

Our system has been improved during the year, in that we have discarded the use of a separate culture outfit for secondary examinations, and have simplified the little book now used for all outfits alike.

Results of the Examination of Cultures.

During the 312 working days of the year 5,981 cultures were examined, making an average of nearly 19 each day. The whole number consisted of 2,385 cultures made from the throats of persons showing evidence of disease; 29 cultures from persons exposed to cases of true diphtheria, giving a total of 2,414 cases, from whom 3,567 secondary cultures were examined. These latter are for the purpose of determining when a patient is free from danger to others, that is, when diphtheria bacilli can no longer be found in the throat.

Of the 2,385 cultures mentioned above 1,442 or 60.4 per cent. showed on microscopic examination the presence of true diphtheria bacilli; 674, or 28.2 per cent., did not show their presence and we were unable to make a satisfactory examination of 269 cultures.

Comparison of the Clinical and Bacteriological

Diagnoses.

Attending physicians stated their clinical diagnosis in 571 cases or 23.9 per cent. of the 2,385 cases showing signs of disease. Such clinical diagnosis was verified by the bacteriological diagnosis in 355 cases or 62.1 per cent.

Their diagnosis of diphtheria was verified in 267 cases or 71.3 per cent. It was not verified in 74 cases or 19.7

118

per cent., and we were unable to make a satisfactory examination in 34 cases or 9 per cent.

Their diagnosis was other than diphtheria in 196 cases, and was verified in 88 or 44.9 per cent.; was not verified in 90 or 45.9 per cent., and in 18 cases we were not able to make a satisfactory examination.

Of the 1,814 cases in which no positive clinical diagnosis was stated, 1,085 showed the presence of diphtheria bacilli; 512 did not, and in 217 cases a satisfactory examination was impossible.

An examination of the above results will show the importance and value of the diphtheria diagnosis work. We find that this laboratory gave a positive diagnosis to physicians attending 2,116 cases of suspected diphtheria, and that we were able to state that 1,442 were cases of true diphtheria, and that 674 cases were not true diphtheria.

While many physicians sending cultures are quite sure that their clinical diagnosis is correct the majority of them are not sure, and the number of those of the latter group is increasing. In the year 1895 a clinical diagnosis was not given or doubt was expressed in 41.5 per cent. of all cases, while in the year 1896 the number was increased to 76.1 per cent. of all cases. This would indicate an increased dependence upon bacteriological examination for diagnosis. This 76.1 per cent. represents, 1,814 cases and in 1,085 of them true diphtheria bacilli were found; in 512 they were not found and it was impossible to make a satisfactory examination in 217 cases. It can be easily seen, therefore, that the laboratory was able to make a positive diagnosis in almost all cases where the physician was not sure of the true nature of the case.

In 375 cases where the physicians did make a definite clinical diagnosis of diphtheria we found true diphtheria bacilli in 267 or 71.3 per cent. but we did not find the specific bacillus in 74 cases or 19.7 per cent.