Læknablaðið - 01.12.1978, Page 67

LÆKNABLAÐIÐ
201
to something attacking these children in
later years of childhood. Miller suggested
that this might be the natural involution
of the tonsils and adenoids taking place
about the age of 8 years. This much inte-
rested us as the tonsils are rarely a primary
focus of disease in either H.D. or in the
Burkitt lymphoma in Africa whereas they
are relatively common initial foci of dis-
ease in lymphosarcoma and so called
,,histiocytic“ sarcoma. Earlier studies had
suggested that prior appendicectomy in-
creased the liability to H.D.21 We decided
to see if prior tonsillectomy acted similary.
To do this we selected an area of Long
Island, in New York State, the counties of
Nassau and Suffolk. This was in a rapidly
developing area of high recent internal
immigration, an affluent society with a
high proportion of yong people, an edu-
cated and cooperative public and where
the medical services were excellent and
abundant and where the overwhelming
majority of H.D. cases were initially dia-
gnosed in the locality. Slides could be
reviewed, and all were, and patients and
relatives interviewed, and we confined
attention to persons under 40 years of age
where the history of prior tonsillectomy
was verifiable. Adequate controls where
used as in all our studies. The results of
this study showed that a prior tonsillec-
tomy increased the liability to the subse-
quent development of H.D. by a factor of
2.4.48 This it should be noted is of negli-
gible public health importance but poten-
tially of great biologic significance. Our
findings have been both denied and con-
firmed by subsequent studies but the more
careful of these have come to similar con-
clusions though it is uncertain if this in-
creased liability is related to social or bio-
logical factors.14
At this junction our attention was shifted
to the role of high schools in the epidemio-
logy of H.D. in the U.S.A., or at least of
large central high schools.49 50 It is easiest
to approach the Albany outbreak after
describing other situations. In one, 3 cases
of H.D. developed in students who were
closely involved with other persons who
remained in good health but who seemingly
passed the disease to other persons, after
going to other areas.50 In the other out-
break, a school teacher with H.D. was in
close contact with five individuals who
subsequently developed the disease and the
two other cases in the community lived in
houses where a student was living who had
been in classes with the teacher and af-
fected students but who remained in good
health. These were the only cases of H.D.
in a large affluent community over a 10
year period and all related — directly or
via one contact — to this affected teacher,
both by a scholastic and a personal contact
network.50
Thus, in these two instances, we saw
what could be interpreted as case-case
spread and possibly of case to contact to
case spread. I stress the word ,,could“ as
other interpretations are possible for we
have no means of identifying any factors
which might be passing, nor anyone who is
a carrier other than by the indirect means
of identifying such an individual through
a developed case of H.D. We have no test
for this disease other than the histology.
However, we were invited to investigate
an alleged outbreak of H.D. in a local high
school.40 50 7 We did not embark on the in-
vestigation with any enthusiasm or high
expectations. We were given seven names.
One did not have H.D. but had dropped out
of school with enlarged neck glands, a
second was also free of disease but in her
school life lived with her father who
subsequently developed H.D. Five students
developed the disease, one girl had a boy-
friend who ceased the acquaintance once
she developed the disease but shortly after
he married another girl who later did
develop the disease. All save this last
patient were students in very close contact
with one another, both in and out of school.
Was all this coincidence or was it an
example of the case-case, or case contact
case spread I have previously mentioned?
The school authorities provided us with
student lists and luckily the student re-
cords included lists of the close friends of
each student. Thus, before we had any
idea of the extent of outbreak we had
identified a close knit group of students