662 THE PROBLEM OF THE DIPHTHERIA CARRIER.

by external manipulation. The painting by Rembrandtin Brussels depicts the young Tobias performing an opera-tion for cataract on his father. In the Lutheran translation

of this miracle the word leucoma is freely translated ascataract, which is retained in the Dutch Bible of to-day.Greef’s hypothesis is the less credible, as it is highlyimprobable that bile rubbed into the eye could remove a

pterygium, whereas it is conceivable that old Tobit rubbed

his eye vigorously after the instillation of bile, and that

he thereby dislocated his lens. If this be the correct

interpretation, Rembrandt’s painting is at fault only withregard to the cataract needle held by Tobias. The paint-ing is the best portrayal of an operation for cataract

which has hitherto been made, and Rembrandt was pre-sumably assisted by v. Meekren, an old pupil of Tulp,whose views as to the impossibility of curing cataract

by external manipulations probably coincided with those

of Greef. According to yet another theory Tobit sufferedfrom a serpiginous ulcer of the cornea which is treated tothis day with the instillation of bile. But such a cure

cannot have been so spontaneous and rapid as the restora-tion of sight by the dislocation of the lens which, as theabove case shows, may occur with that suddenness which isone of the essential features of a miracle.

THE PROBLEM OF THE DIPHTHERIACARRIER.

THE importance of the apparently healthy carrier of

infective organisms in regard to the spread of many

specific infectious diseases has become increasingly apparentsince attention was first drawn to the question in the caseof enteric fever. The recognition of this factor in their

spread has opened out a new field of work in the prophy-laxis of some of these diseases. In none is the problemof greater importance than in the case of diphtheria, andthe difficulties in the way of dealing with the carrier of

the bacillus of this disease render any careful study ofthis question noteworthy. We have received a monographentitled "A Study in Epidemiology illustrated by a

Diphtheria Epidemic," privately published by Dr. AngusGraham Macdonald, in which, among other matters, this

question of carrier cases is considered in some detail, andin which a scheme is suggested for endeavouring to dealwith it. The basis of h;s observations is afforded bya careful study of an epidemic of this disease occurringin Crewe during the months from March to August,1910.1 Ninety carrier cases were isolated in associa-

tion with 157 cases notified. The contacts were divided

into home and school contacts, and there were 534

of the former yielding 62 positive cases or carriers, and 644of the latter with 28 carriers. In addition 774 bacteriologicalexaminations for release from quarantine were carried out,yielding a total of 2326 examinations. All school-carriers

were found to be intimately associated at play with othercases and with carriers, but mere class-room proximity wasfound to be of little importance as a factor in spreading thedisease. The evidence also goes to show that very intimatemeans are necessary for the transmission of diphtheria fromone individual to another-a point which Dr. Macdonald

regards as of great importance in indicating how readily thedissemination of the disease may be prevented by promptbacteriological examination and detection of positive contactsor carriers. These carriers are divided by the writer intofour definite groups-first, those who show no clinical

evidence of diphtheria in whom the bacillus is found for a

Ishort time; second, cases in which there is a history of"cold" or "sore-throat" some time previously, these

1 THE LANCET, March 25th, 1911, p. 795.

being probably neglected cases of diphtheria. The third

group comprises patients without clinical history of diph-theria, but presenting some local lesion in the throat, nose,skin, or ear, in which the diphtheria bacillus finds lodgment,the commonest example being membranous rhinitis. Thefourth group is made up by patients who have passed througha definite attack of diphtheria, and in whom the bacillusremains for lengthy periods after convalescence. The fateof the bacillus when it disappears is not obvious. There is

no evidence of phagocytosis, and the suggestion offered asthe most probable explanation is that it disappears as aresult of the growth of some other organism. The admini-stration of antitoxin appears not to influence the existence ofthe organism either in case or carrier. Dr. Macdonald sums

up his observations upon carriers in a series of statements,among which we may mention that the length of carrier-lifeof the bacillus appears to have no effect upon its virulence,since the organism has been proved to be virulent afterfour and eight months in the ear and nose. He main-

tains that the control of diphtheria depends on thecontrol of the carrier as well as of the case, and

he urges that the carrier should be notified, no matter

of what age or sex, and that due quarantine and observationshould be maintained until satisfactory disappearance of thebacillus. He believes that a determined attack on the diseaseon the lines of thorough bacteriological investigation shouldhave no difficulty in stamping out diphtheria altogether. Heclaims that the distribution of the disease which persistsendemically is due to undiscovered carriers, and that

epidemicity depends entirely on the number and nature

of the carriers. After a critical examination of all

the facts collected in relation to the particular epi-demic investigated, Dr. Macdonald outlines his scheme

for dealing with the disease. It affirms that a bac-

teriologist should be an essential member of the publichealth staff. He recommends isolation in a case as earlyas possible after notification and adequate disinfection. In

the investigation of each case he advises a thorough inquiryinto the history of the patient and into his environment, andurges that swabs should be taken from the patient, from allhome contacts, and from as many outside contacts as

possible. Until bacteriological reports are obtained allcontacts are to be isolated. All contacts found to be

positive are to be treated as cases of diphtheria. Dr.

Macdonald’s monograph is a thoughtful and suggestivestudy of a complex problem, and deserves to be carefullyconsidered as a practical contribution to the study of pre-ventive medicine.

____

THE STUDY OF TROPICAL DISEASES.

A MEETING was held on Wednesday, Feb. 28th, at theMansion House, by permission of Sir Thomas Crosby, M.D.,the Lord Mayor of London, in support of the London Schoolof Tropical Medicine, when Mr. Lewis Harcourt, the Secretaryof State for the Colonies, delivered an impressive appeal forthe public support of the school. He detailed the vast andvaluable work which had been done in our far-off de-

pendencies to mitigate the ravages of tropical diseases,or to discover and eliminate their causes, and claimedon good grounds that the keepers of the nati3nal

purse had not been niggardly in their contributionsto the work. A few days later H. S. H. Prince Louisof Battenberg, taking the chair at the annual dinnerof the London School of Clinical Medicine, suppliedadditional arguments for public digestion why the people ofthis country should endeavour to support, and support pro-fusely, the grand medical work now being done throughoutthe borders of our vast Empire. The medical services,Naval, Military, and Colonial, are now collaborating with