Mortality Summary for the Week Ending Saturday Noon, January 7, 1922.

*Corrected by redistributing deaths according to borough of residence.

Deaths According to Cause, Age and Sex

tIf the deaths under one month numbering 105 from all causes, be deducted from the total deaths under one year, the resulting rate will be 41 per 1,000 births (weekly average).

*Includes deaths from Erysipelas 7, Syphilis 6, Diabetes 33, Alcoholism 4, Locomotor Ataxia 3, Paresis 4, Arterio-sclerosis 69, all other congenital causes 14.

Published weekly by the Department of Health, City of New York, 505 Pearl St., New York, N. Y. Entered as Second-Class matter October 16, 1917, at the Postoffice at New York, N. Y. Under Act of March 3, 1879. Subscription, 10 cents per annum.

ROYAL S. COPELAND, M. D., Commissioner of Health.

NEW SERIES, Vol. XI.

JANUARY 21, 1922.

No. 3.

DANGERS OF THE SPREAD OF SMALLPOX.

The year just closed saw an increased prevalence of smallpox in many parts of the country. Within the first six months of the year, about 18,000 cases of smallpox were reported in those states (the "Registration Area"), where a reliable method of registration exists. While the type of smallpox which has been epidemic on an extremely large scale in various Canadian, western, and southern cities, has been mild during the past decade or more, and while the number of deaths have been extremely few, there has been noted, during the past year, a marked intensification of the virulence of the malady, especially in Louisiana and Kansas, where a case fatality rate of more than 10 per cent has been reported. It is possible that the Convention of the American Legion, which was recently held in Kansas City, and which was followed by the dispersion of the thousands of delegates to various parts of the country, may have been the means of spreading smallpox. While this is problematical, at all events it is a fact that the tides of travel bring into this city millions of visitors annually, many of them from parts of the country where smallpox is prevalent on a relatively large scale. In many of these places public health organization is so crude, or lacking in development, that cases of smallpox are not even quarantined. In view of the increase in prevalence and of the increased intensity of smallpox, it is necessary for the Department of Health to be alert in ferreting out every possible contact case in instances where a case of smallpox is discovered. During the year, there were 9 such cases of smallpox discovered in New York City; two of them in a very large shoe factory where, owing to the co-operation of the employers and employees, more than 500 vaccinations were performed.

In the interest of public welfare, and in order that smallpox may not gain a foothold in this city, the Department is empowered to exclude from work and isolate in the home for purposes of observation every person who has been in contact with a smallpox patient, and who refused to permit smallpox vaccination. The acceptance of vaccination by those who have been exposed to smallpox is a matter that concerns not only their own health, but the safety of others, and if they do not voluntarily accept such protection they must be excluded from contact with the general public for a period of 21 days, so that we may observe them, and assure ourselves that they are not developing the disease.

Revaccination of persons who have not been vaccinated for seven years or more, is extremely necessary. It is needless to say that children and others who have never been vaccinated stand in the greatest danger from smallpox. The conditions that prevail with reference to this malady, in the country as a whole, indicate that we must be on our guard against a disease which seems to be spreading rapidly, because of the large numbers of persons in other cities who have not been vaccinated. Especially significant is the fact that the severity of the disease has been so greatly intensified.

During the year 1921, there were 29 cases of smallpox reported in the Greater City. Of these, 9 were secondary, or contact, cases and 14 came from out of

town.

THE DIFFERENTIAL DIAGNOSIS OF SMALLPOX.
An Interesting Case.

Variola, as is well known, has followed a very mild course in New York City, in fact throughout the country, for several years. This lack of virulence has resulted in modifications and abbreviations of both subjective and objectiye symptoms. The disease is frequently afebrile, after the appearance of the rash. The lesions may be so few in number (less than a score) that their distribution is indeterminate. Few, or none, of them may go on to pustulation. Desiccation may be well on the way by the middle of the second week; and complications and sequelae are practically unknown. With all these attenuating, and often confusing, departures from type, the prodromal period still runs true to form. It is invariably from three to four days in duration, and the patient is sick, with fever, and malaise, accompanied by either headache, backache, or abdominal pain, or all of the three. This syndrome is such an exact counterpart of the onset of influenza that it is common for a diagnosis of smallpox to be preceded, by three or four days, with a diagnosis of influenza. The following is an interesting case in this connection:

Patient, H. A., a boy, six years old, was taken sick, suddenly, with fever, malaise, vomiting, severe headache, and backache. Symptoms persisted, with temperature reaching 103° F., for four days, during which time there was no reason for doubting the correctness of the diagnosis of influenza.

On the 5th day, subjective symptoms had disappeared, and the patient felt entirely well. There were, however, generally distributed over tace, forearms, backs of wrists, and shins, some two or three score maculo-vesicular lesions. There was scarcely a lesion on the trunk and none on the scalp. The illness exactly corresponded, both in character and duration, to the prodromal period of smallpox; and the distribution of the eruption was centrifugal and strongly suggestive of the same disease.

While the case, certainly, was one to arouse suspicion, and was deserving of another inspection on the following day, there were points about the eruption that did not indicate variola. In the first place, there was fluid, appreciable to the eye, in some of the lesions, within twenty-four hours of their first appearance. In varioloid, the life history of the skin lesions is abbreviated; some of the stages are hurried through, or even omitted. Still we do not expect, usually, such a degree of precocity. In the case in question, although the lesions were more numerous on forearms and legs than on arms and thighs, there was not a lesion on hand or foot. Such a distribution is not to be expected.

On the following day, many of the lesions had disappeared and those still present were receding. There was no scab formation. The diagnosis of influenza was allowed to stand-the rash being considered as probably due to medication.

PREVENTING DIPHTHERIA.

The district nurses have been instructed to notify headquarters when, in the course of their day's work, they find children, who are exposed to diphtheria, and who might properly be presumed to be susceptible because they have not been Schick tested and found to react negatively, or, because they have not been actively immunized by toxin-antitoxin. The object of such prompt notification is to enable the Department to get in touch with the family physicians, in order that they may be persuaded to immunize all exposed persons, since delay in immunization has so frequently been found to be the cause of the development of diphtheria, which could have been easily, surely, and safely prevented by the timely administration of a small immunizing dose of antitoxin. To fail to give such prompt immunization, unless the exposed, children are known to be "sensitized" or especially susceptible to the effect of horse serum, shows the greatest negligence. Headquarters will inform the said family physicians that it is their duty to immunize susceptible persons in the family, unless a very definite contraindication exists, and will offer to perform immunization for the physicians, with the latters' consent. Physicians who fail to immunize, in the face of such warning, incur a serious liability, and it is therefore our duty to advise them and urge them as strongly as possible to protect themselves by offering immunization, promptly, or else to let the Department perform it. It is well to bear in mind, in this connection, that children who have had several attacks of diphtheria are not necessarily immune to the disease. It is obvious that the Schick test, which is a perfectly safe procedure, is the logical measure which all parents in the City should be educated to have applied to their children, when they are well, and have not been exposed to diphtheria, in order to discover whether they are in danger of contracting the disease. If children, as the result of the application of this special test, are shown to be susceptible to diphtheria, immunization by toxinantitoxin is, of course, the only logical and safe procedure.

Arrests.

880

PREVENTING SMOKING IN THE SUBWAY.

VIOLATIONS OF SECTION 216, SANITARY CODE, GREATER NEW YORK, 1921.

The above gives the court record of the efforts of the Sanitary Squad to prevent smoking in the subways during last year.

"THE WEEKLY BETTER TIMES BULLETIN."

A weekly bulletin presenting the news of all charitable and social welfare work in New York has made its initial appearance, according to an announcement made by Miss Lillian D. Wald, for a committee of persons prominent in philanthropic work.

The new publication, to be known as "The Weekly Better Times Bulletin" will be issued as a supplement to "Better Times," a monthly magazine devoted to the activities of the 2,000 charitable and social welfare organizations in this city. The weekly bulletin will report the gist of the current news of local philanthropic and welfare