tion by the Veterinary Board of lower Austria. This milk very closely resembles human milk in its chemical composition. It is sterilized at 102° C.

The process of pasteurization has absolutely no effect on the nutritive value of the milk while rendering its taste more pleasant; neither does it affect the formation of cream. The system has been in use for seven years; and the beneficial effects of the improved milk supply, especially with regard to the feeding of infants, are demonstrated by the statistical data. (See chart.) The proportion between the mortality rates for breast-fed and bottle-fed children was formerly (especially in the summer months) 1:20, while it is now from 1:5 to 1:8. The circumstance that bottle-fed children are given better milk reduces the rate of mortality for those in the second year of life also. Regarding the cost of the milk, the process of pasteurization increases the price from 3-10 to 1 heller per liter (1-13 to 1-4 cent per quart).

LATENT DIPHTHERIA.

A PUBLIC HEALTH PROBLEM.1

MYER SOLIS-COHEN, A.B., M.D., Instructor in Physical Diagnosis, University of Pennsylvania, Philadelphia.

Causes of Diphtheria Prevalence.

From the public health viewpoint, diseases are studied in order to prevent their spread. Effective prophylactic measures, based on scientific observations, have caused some infectious diseases to disappear from civilized communities, while others have become comparatively rare. Yet, despite the ever-increasing knowledge as to its bacteriology and methods of propagation, diphtheria still remains a fairly common affection. Why is this?

One reason is that only the well-marked cases are isolated and placarded, while persons suffering from the milder forms of diphtheria are permitted to walk the streets, attend school and frequent public places. Another unguarded avenue of contagion is kept open through the false sense of security given by the rules now in vogue as to disinfection. Fomites, which, as shown by Chapin, Hill, Weichard and Welch, only rarely contain the germs, are required to be disinfected, while no attention is paid to the virulent bacilli which so frequently are present and persist for long periods in the noses or throats of persons with whom

1 Reprinted from the " Journal of the American Medical Association," July 6, 1907.

the patient has been in just as intimate contact. The fault lies partly with physicians, who do not recognize the latent forms of diphtheria, and partly with sanitary officers, who fail to seek out and guard as sources of infection all those who are liable to transmit the disease.

The Author's Cases of Latent Diphtheria.

I have seen 27 cases of latent diphtheria, most of them in my capacity as assistant medical inspector of the Philadelphia Bureau of Health. I regard as diphtheria any pathologic condition, local or general, due to infection by specific diphtheria organisms, as defined by Williams, and apply the term latent to those forms unassociated with pseudo-membrane.

Case 1. J. S., a schoolgirl of about twelve years, presented enlarged and reddened tonsils on April 29, 1904, and was excluded from school for tonsilitis. A culture taken at the time and one taken later both contained diphtheria bacilli. The girl was not sick at any time.

Case 2. N. McI., a girl of about fifteen years, had been undergoing treatment by her family physician for chronic sore throat. She complained of pain in the throat and a general feeling of soreness in the body while at school May 12, 1904, and on examination her tonsils were found to be red and swollen. She was excluded from school for "rheumatic sore throat." A culture showed the presence of diphtheria germs. Despite active treatment by means of disinfectant sprays, swabbings and gargles, the diphtheria bacilli persisted in the throat until May 23. The girl felt perfectly well generally the day after she was sent home, but on May 20 the throat was still sore.

Case 3. - W. L. had a reddened throat and seemed to have fever in school on May 7. Bacteriologic examination was positive. In a day or two the throat was normal. The boy was never sick. Yet the diphtheria bacilli persisted for five days.

Case 4. G. W., boy, aged about fifteen years, on May 9, at school, presented a reddened throat, a culture from which proved positive. The boy felt perfectly well and the next day his throat was normal in appearance. The bacilli nevertheless persisted for five days.

Case 5. C. R., a boy of about eight years, was excluded from school for tonsilitis, his tonsils being reddened and swollen. He returned in a week with the throat condition unchanged and was again excluded. He had been without medical treatment. On May 12 he returned without showing improvement, and a culture was taken which proved positive. The child was not sick, but looked unhappy.

Case 6.-F. C., a little child in a home for colored cripples, had been exposed to true diphtheria on May 15; her fauces were reddened and contained diphtheria bacilli. Her throat did not feel sore. It was examined on several occasions and never gave any evidence of diphtheria. The child was well and playing around. She was given no antitoxin.

Case 7.-S. S., a child in the same home, was exposed to the same contagion. Her throat, though practically negative when examined on May 17, contained diphtheria bacilli. The child's pulse was rapid. There was no other sign of diphtheria.

Case 8. J. A., another child exposed to diphtheria in the same home, was given an immunizing dose of 500 units of antitoxin, although her throat on May 15 gave a negative culture. On May 22 she complained of her throat feeling sore, and though on inspection the throat looked clear, a culture proved positive. The child was well and about.

Case 9.-O. P., a little colored boy, day after day, at school, would complain of headache, which, he said, had persisted since an attack of tonsilitis three weeks before. Nothing wrong could be found on several examinations. Finally, on May 23, a culture of the throat was taken, which showed the presence of diphtheria bacilli.

Case 10.-E. O. N., living in the house where her brother was sick with true clinical diphtheria, developed a mild sore throat which gave a positive culture. The child was not very ill and did not require antitoxin. There was no membrane in the throat.

Case 11. — M. M., a girl of about eight years, complained at school for several days of headache, nausea and sore throat. When examined on May 27 the throat contained diphtheria bacilli, which persisted until June 20. There was no pseudo-membrane in the throat at any time.

Case 12. -M. P., a girl, lived in an orphanage in which four cases of diphtheria had occurred in two weeks, despite the fact that as soon as discovered each patient was removed to the Municipal Hospital for Contagious Diseases, and the orphanage was disinfected. The medical inspector heard of seven children with tonsilitis having been isolated for several days in the infirmary and promptly took cultures of their throats on May 25. This child was one of four who gave positive cultures. Her throat was perfectly clear at the time.

Case 13. J. L., a boy isolated for tonsilitis at the same orphanage, when examined had a clear throat, which nevertheless contained diphtheria bacilli. Case 14. — R. S., a boy, also isolated for tonsilitis in the same way, gave a positive culture, although his throat was clear at the time.

Case 15.-A. H., a boy, was the fourth of those isolated for tonsilitis who were suffering from latent diphtheria. His throat also was clear when examined.

Case 16. - F. B., a boy of about eight, was told by his mother to consult the medical inspector at school to find out the cause of his having "kernels" in his neck. She said he was subject to them. On examination the tonsils were seen to be very large, but there was no sign of a deposit. The boy had not been ill at all. He was excluded for tonsilitis, and a culture was taken on June 2 that proved positive. A culture four days later was negative. At the time of the first examination, on May 2, and for two days following, the child's four-year-old brother, E. B., suffered from stiff neck. A culture of his throat was taken on June 7. Although no abnormal appearance was noted

the culture was positive, and when the child (E. B.) was seen two days later he was sick that day (June 9) for the first time. A typical diphtheritic membrane covered the back part of the tonsils.

Case 17.-H. H., a boy of about ten years, complained June 3, while at school, of headache, belly ache, nausea and vomiting. His throat was slightly inflamed. Otherwise the child was apparently well. A culture was taken and proved positive. Although the symptoms complained of had disappeared by the next day, the diphtheria bacilli persisted for more than a week.

Case 18. — L. A., a girl of about eleven years of age, was sent from home the moment her brother was taken sick with undoubted clinical diphtheria, but she continued to attend school. Twelve days later her throat was examined, and the tonsils were seen to be enlarged and reddened, but no patch was anywhere visible. The child complained of no subjective symptoms; her throat did not feel sore nor did she experience pain in deglutition. A culture taken on Sept. 19, 1904, contained diphtheria bacilli. On October 5 the tonsils were greatly enlarged and reddened and still gave a positive culture. The diphtheria bacilli did not disappear until October 11, on which day the tonsils were still reddened and were greatly enlarged, almost meeting in the median line. This was six days after the child sick with clinical diphtheria had given a negative culture.

Case 19.-J. R., a girl of about eight years, was absent from school for ten days with sore throat, but received no medical attention. She returned to school November 21, and remained in school until November 23. Her two sisters were stricken with true clinical diphtheria on November 22. The child at that time appeared perfectly well.

Case 20. — E. G., a boy of about eleven, on November 22 was in the same room with the sister of the patient in Case 19, who developed true clinical diphtheria that same day. The boy (E. G.) had always had hypertrophied tonsils and was subject to frequent attacks of tonsilitis, which was almost constant during the fall, winter and spring. He had been no worse during the past few weeks than previous to that time. His tonsils were enlarged, shiny and reddened on November 28, and contained diphtheria bacilli which persisted for five days.

Case 21.-J. M., a girl, on December 13 was sent to the medical inspector in school on account of a swelling in the neck. The tonsils were reddened and enlarged and were prominent externally. There were no white spots and no other symptoms. The child had had pain in her ear, etc., a week previously. The throat gave a positive culture, but two days later the culture was negative.

Case 22. J. B., a boy, in school December 7, had a sore and reddened throat, which gave a positive culture. A week later a culture of his throat proved negative.

Case 23.-F. S. was referred to the medical inspector at school on account of otorrhea. A routine experimental culture was taken, which proved positive. When the child was seen a few days later, on Jan. 9, 1903, there was no sign of diphtheria and the throat gave a negative culture.

Case 24.-W. G. M., on January 20, complained in school of a headache and presented a mild pharyngitis. A culture taken from his throat contained diphtheria bacilli, which persisted until February 8.

Case 25. ·M. S., a girl, had tonsilitis in school on February 8 and her throat gave a positive culture. Her physician said that he found no tonsilitis, but on February 10 the medical inspector, when taking a culture that proved negative, noted that a mild degree of tonsilitis was still present.

Case 26.-J. S., a girl, complained of headache in school on February 10. She felt ill but did not suffer pain on swallowing. There was slight reddening and swelling of the tonsils, but no white patches were visible. A culture showed the presence of diphtheria bacilli in the throat. A couple of weeks previously an aunt had had a white spot on her throat which received no treatment. On February 13 the girl still felt ill. Her throat was slightly inflamed and ulcers were present on the inside of her lower lip. Cultures from both the throat and the ulcers were negative.

Case 27.-L. C., a little girl, developed dysphagia on June 29, 1905, the tonsils being enlarged but not reddened. The temperature was 101° F., and remained elevated for two weeks. The pulse averaged about 116. On July 7 the tonsils were still swollen and the crypts were filled with secretion. The urine at that time contained a minute trace of albumin but no casts. Breathing became very noisy, but after an application of adrenalin solution was much easier. The child was put on a gargle of 1⁄4‰00 formaldehyd solution, and silver nitrate, 60 grains to the ounce, was rubbed on the throat. The breath was foul. On July 10 the crypts were still filled with white secretion and a positive culture was obtained. The next day the tonsils were still swollen, but no membrane or secretion could be seen. The following day the throat was clear. The second negative successive culture was taken on July 16.

It is only fair to state that the bacteriologic laboratory that reported these cultures as showing the presence of diphtheria bacilli regards all bacteria morphologically indistinguishable from typical diphtheria as true Klebs-Loeffler organisms, and takes no account of the so-called pseudo-diphtheria bacillus or Hoffman bacillus. Consequently, a question as to the identity of the bacilli found may be raised by those who believe that the two organisms belong to different species. Such persons need regard as suffering from latent diphtheria only those patients who either were in contact with patients suffering from true membranous diphtheria or who themselves appeared to give rise to cases of membranous diphtheria. This will include Cases 6, 7, 8, 10, 12, 13, 14, 15, 16, 18, 19, 20 and 27. The other cases, 1, 2, 3, 4, 5, 9, 11, 17, 21, 22, 23, 24, 25 and 26, may be regarded as conditions of sore throat caused by diphtheria-like bacilli, although it is my opinion that the greater number, if not all, of these organisms were true diphtheria bacilli.