out the recognition of the almost constant presence of the so-called Koplik spots.

In the diagnosis of a difficult case, or one with which you have little familiarity, let your pride of opinion be tempered with humility, but when in doubt as to the possible presence of a serious communicable disease, never hesitate to take every precaution for the protection of the community even though subsequent events prove them to have been unnecessary and your reputation as a diagnostician suffers in consequence. Not one of us is sufficiently wise or experienced to express a definite opinion of the bacteriological cause of every pseudomembrane which occurs, especially in the throat, without the help of the laboratory. The greatest toxin producer known is a diphtheria bacillus originally cultured from a mild case of clinical tonsilitis. In every case, especially when the patient is a young child, which may be diphtheria, give antitoxin, take cultures and reserve your final decision until you have received a report from the laboratory. This advice has been so constantly given by the Department that most of you will regard it as unnecessary to repeat it here. Yet in the past two weeks I have heard of a health officer who boasts that he never gives antitoxin until he has heard from the culture.

During local epidemics of diphtheria, especially in school children, every sore throat of whatever clinical character should be suspected to be diphtheria, and treated accordingly. When pseudomembranes persist after an adequate dose of antitoxin for days and weeks, and reports from the laboratory are all negative, do not continue to give antitoxin or blame the bacteriologist, but send a smear to be stained and examined for the presence of the anaerobic bacteria which are the cause of Vincent's angina.

Beware of croup! If in addition to the symptoms indicating laryngeal involvement there is present the smallest patch on a tonsil, the case is diphtheria and should be so treated. Again if there is no such patch, but the ordinary remedies of heat and emetics fail to bring relief within a reasonable time, that case too in all probability is diphtheria and should be so treated. Let me here remind you that in taking cultures from the latter case, the swab should be slightly bent and the culture taken from the interior of the larynx, otherwise many cases of true laryngeal diphtheria will give negative cultures.

Whether or not the organism of scarlet fever has finally been discovered as claimed by Mallory, I venture to prophesy that sooner or later it will be established that the symptom-complex of the disease is dependent for its full development partly on the action of streptococci, especially those of the haemolyzing type, in other words upon the combined action, symbiosis, of the organisms.

Streptococcus infection of the throat, wounds and uterus when accompanied by an eruption can not be distinguished by any means known at the present time from scarlet fever, and even if there is not the slightest evidence of previous exposure to be obtained, such cases should be regarded as scarlet fever and handled accordingly.

The recognition of the average case of scarlet fever presents no difficulties except to those with little or no experience with the disease. The diagnosis of a typical case often presents one of the most baffling problems in clinical medicine. However poorly marked elsewhere, the eruption with the rarest exceptions is always present in front of the axillae, in the groins and on the back. It is very infrequently seen above the chin-ear line. The lymphatic nodes of the cervical region, axillae and inguinal region are more or less enlarged, after the first 48 hours. The typical evolution of the mucous membrane of the tongue may occasionally be lacking; when present it is one of the most reliable diagnostic signs.

I do not believe that scarlet fever can be present without some involvement of the pharynx although in certain cases this may not be well marked. On the other hand there is a good deal of evidence which goes to show that scarlet fever may occur and even in a severe and sometimes fatal form, with involvement of the throat alone, and without an eruption on the surface of the body.

I wish to emphasize the fact that the eruption of scarlet fever in the vast majority of cases persists for at least 24 hours and one should avoid making a diagnosis of the disease on the presence of an eruption which disappears in a few hours, especially if the throat is normal. In making a differential diagnosis between scarlet fever, German measles, measles, serum rashes and rashes of intestinal origin, one must take into account all the symptoms and signs present, as well as those which are lacking and base the final judgment on the preponderance of evidence for or against each disease, but even with the greatest experience and with thorough examination it is sometimes impossible to form a definite opinion, and in such cases it is the absolute duty of the health officer and physician to take such measures as will protect the public against the consequences of turning loose a case of communicable disease because it was thought to be some harmless and noninfectious condition.

Epidemics of septic sore throat are explosive in character. The virulence of the infection varies in different epidemics as well as in individuals in the same epidemics, the symptomatology is so variable that it is hardly possible to give a concise description of the disease. Thus in the same epidemic there will be many cases of mild and severe pharyngitis, of mild and severe tonsilitis of the catarrhal, pseudomembranous or follicular type. There is always a decided tendency to

involvement of the cervical nodes, especially during convalesence, while general septic peritonitis is not an unusual and fatal complication. In many epidemics there are a certain number of cases which cannot be distinguished from scarlet fever. The presence in the throat, as shown by culture, of streptococci of the haemolyzing type serves to confirm the nature of the disease but the principal factor which should arouse suspicion and on which a diagnosis should be based is the sudden occurrence of a large number of cases of sore throat in a community which in the vast majority of cases signifies a milk supply infected with streptococci of human origin.

German measles and varicella are of importance principally on account of the frequency with which they are confused with much more serious diseases the first with scarlet fever and measles- the second with smallpox.

German measles comes in waves usually with long intervals between and affects a large number of people, adults as well as children. The first few cases are frequently not recognized or diagnosticated as measles, or mild scarlet fever. This is quite excusable but the recognition of the disease should not be long delayed with careful observation of individual cases. A few cases cannot be definitely differentiated from scarlet fever and measles. The main points upon which such differentiation should be based are briefly as follows: In the scarlatini form type of German measles the eruption usually involves the face which is an extremely rare occurrence in scarlet fever. Even with a vividly red eruption involving the entire body, the fever is very much lower than would be the case if such an eruption were due to scarlet fever and the pulse rate usually so high in scarlet fever is but little accelerated. The eruption is apt not to be uniform but may resemble measles on one part of the body and scarlet fever on another part. Unfortunately this sometimes also occurs in scarlet fever.

In German measles the throat may be remarkably reddened and extremely painful — a fact often not dwelt upon in descriptions of the disease. The tongue is not that of scarlet fever, while the presence of enlarged cervical nodes is characteristic of the disease provided other causes are not present to account for it, notably pediculosis of the scalp. Finally, if one can make a blood count and microscopic examination the lack of leucocytosis points to the presence of German measles. I believe that determination of the presence or absence of the so-called inclusion bodies, as first described by Döhle, is of decided value in helping to arrive at a differential diagnosis. Save for the absence of Koplik spots and the presence of enlarged post cervical nodes German measles may resemble true measles so closely as to be indistinguishable.

In the vast majority of cases the prodromata of German measles are much less marked or may pass unnoticed. The fever is lower, the eruption less general and usually of a somewhat different shade of color, while the catarrhal symptoms in the conjunctivae and tracheo-bronchial tract are slight or absent.

Between varicella and smallpox the differential diagnosis is usually simple and rests largely on the simultaneous presence on a circumscribed area of skin, of papules, vesicles and crusts. The fever of varicella is usually slight but it may be very high and accompanied by marked constitutional symptoms.

Rarely in varicella there may be more or less general pustulation and still more rarely a gangrenous involvement of the lesions, such cases giving the greatest concern to the diagnostician. In a number of instances in New York City, resort has been had to the inoculation of some of the contents of a lesion into the skin of a monkey as a means of differential diagnosis a "take" indicating the presence of smallpox.

I shall not dwell here on the diagnosis of typhoid fever, except to urge you to suspect all cases of continuous fever and take blood for the Widal test, not once, but as long as the fever lasts, or until a positive report is obtained, or the febrile condition otherwise definitely accounted for. As a matter of routine it is well to send also to the laboratory a properly made blood smear to be examined for malarial parasites, especially in the case of young children who are running a continuous fever.

Those who have a laboratory near at hand should, also, take blood cultures, a procedure however, which requires a certain amount of practice and training in asepsis.

From the study of the recently compiled statistics of bacteriologic examinations made in the State outside of the large cities, one is led to believe that a rural practitioner possesses some peculiar methods of recognizing pulmonary tuberculosis without the aid of sputum examinations not known to the city physicians, or else that the diagnosis of pulmonary tuberculosis is a matter of indifference, perhaps on account of the lack of proper provisions for its treatment.

Granted that these cases should be treated in sanatoria, room in which is very often unobtainable, nevertheless much may be done in the home not only for the patient himself, but for the protection of the other members of the household.

Upon sputum examination, if necessary repeatedly made, must rest the definite recognition of many cases the nature of which is otherwise unsuspected and not until there is a full realization on the part of the public of the great number of cases of pulmonary tuberculosis demanding hospital care will the provision for such care be forthcoming in full.

THE QUARANTINE CONTROL OF CONTACTS*

PAUL B. BROOKS, M.D.

Sanitary Supervisor, State Department of Health

One of the "landmarks" in a section of the Adirondack forest in which it has been my fortune to spend several summer vacations is the "fire warden." When a forest fire is discovered, he tells me, every ablebodied man in the vicinity may be pressed into service and, with axe, pick and shovel, an effort is made to circumscribe the burning area and prevent the spread of the flames. Not less important, although possibly somewhat less thrilling and more irksome, is the duty of those assigned to watch for flying sparks and fire-brands and prevent their starting new fires. When the emergency is over an effort is made to discover its origin and to prevent the same thing happening in the same way again.

The health officer has much in common with the guardian of the forest. If he is faithful to his duty he stands guard day after day over the life, health and happiness of the people of his community, ever ready, with tact, nerve and judgment, to note the first signs of impending disaster, ready to apply to its prevention or control the knowledge that a rapidly developing science has placed at his disposal.

Looking in retrospect over my own experience as a health officer, and more recently from observing the work of a considerable number of other health officers, I am led to the conclusion, that we may learn something from the fire warden; that we have been somewhat lacking in foresight and sense of proportion. We have devoted curselves vigorously to subduing the first blaze, but have too often neglected to stamp out the sparks. and fire-brands, and to guard against the occurrence of new fires from the same source. In other words, we have more or less faithfully devoted ourselves to tacking up quarantine signs, laying down rules and regulations, and have even brought the village constable to stand on guard to prevent the victims of communicable disease from going beyond bounds; we have burned our sulphur and generated our formaldehyde, leaving behind us a comforting sense of security and an abundance of disagreeable odors. But we have given far too little attention to seeking out and bringing under observation and control those susceptible persons exposed to, and likely to develop and spread disease, and to locating. and eliminating the source of the first outbreaks.

Underlying all well directed efforts to determine sources of infection. and to discover contacts, there must exist a reasonable knowledge of the nature of the disease, the habits and peculiarities of the causative

* Read at the Annual Conference of New York State Sanitary Officers, Saratoga Springs, June, 1910