The number of deaths from measles begins to increase in December; continues in January and February, attains the maximum in March, and decreases gradually during April, May, June and July. During August, September, October, and November, the least number of deaths occur, while October represents the minimum. The seasonal distribution of cases is shown for 1916 in Table A. Judging from this table, the physician may expect to meet with cases of measles in his practice during the winter and spring.

To summarize, measles is a serious cause of mortality and morbidity in Ohio, besides being the source of considerable economic losses to the community on account of serious interruption to school work. Measles is a predisposing factor to tuberculosis, and causes many deaths from pneumonia, which are not shown as due to measles in mortality tables. The disease is extremely fatal during the age period under five years, and over three-fourths of all deaths from measles occur under ten years of age.

Modes of Transmission.

Measles is transmitted by the discharges of the mouth and nose. It has been shown by the researches of Anderson and Goldberger that the disease is capable of being transmitted only during the febrile period. During the first four days, when the symptoms are those of a feverish cold in the head, the disease is most contagious, and at the same time most difficult to guard. The virus, whose nature is unknown, is present in the discharges of the mouth and nose, and in the blood. It has been suggested, but not proven, that there are chronic carriers of measles, and some observers believe that the discharge from diseased ears following measles may transmit the disease. Measles is spread by cases during the onset, by cases with eruption which are not quarantined, and possibly by chronic carriers. There is no positive evidence that the desquamated skin carries the virus, and some evidence to the contrary has been collected.

Diagnosis and Treatment.

Little need be said about the diagnosis of measles except to warn physicians that the disease frequently exists in mild form, and of course mild cases will have a better opportunity to spread the disease than severe types. Passing mention should be made of Koplik's spots, which enable the physician to make a diagnosis before the exanthem Malignant and hemorrhagic forms of measles are apt to occur in debilitated subjects. "Grippe" and smallpox are not frequently mistaken for measles, or vice versa, during the onset. In the treatment, particular attention should be paid to the eyes, ears, mouth, lungs and heart. Great care should be given to the patient during the stage of convalescence, and when the rash is disappearing, as this is the period when broncho-pneumonia is most apt to supervene. The younger the child, the more apt is broncho-pneumonia to occur. Measles in a child with tuberculous antecedents should be looked upon with suspicion.

Complications.

By far the most frequent and fatal of the complications of measles, is broncho-pneumonia. Holt states that in two epidemics in the Nursery and Child's Hospital, aggregating about 300 cases, nearly all in children under three years, broncho-pneumonia occurred in about 40 percent., and 70 percent. of these died. Pulmonary tuberculosis may terminate an attack of measles, or the latter may aggravate a case of tuberculosis. Tuberculosis is not infrequently a sequel of measles. Cancrum oris, or noma is a terrible complication of measles, and emphasizes the need of care of the mouth. I have seen two cases of cancrum oris, both following measles, and both fatal. The condition in these cases was terrible, almost beyond description, necrosis of the cheek having exposed the alveolus and involved a large portion of the face. Ocular complications are not rare, and vary from an aggravated form of catarrhal conjunctivitis to corneal ulceration, perforation and panophthalmitis. Heart and kidney complications are infrequent. The glands are enlarged in measles but rarely suppurate. Otitis media is not infrequent, and many cases of deaf-mutism are traceable to attacks of measles. Complications affecting the skin, liver and nervous system have been described.

Immunity.

One attack of measles usually confers a definite and lasting immunity, but two or more attacks are not very uncommon. Practically all persons unprotected by a previous attack are susceptible. When measles was first introduced into the Faroe Islands in 1846, over 6,000 of the 7,782 inhabitants were stricken. During the first few months of life the suckling enjoys a comparative immunity. Old age does not protect if there has been no previous attack. Herman, of New York, recently made some interesting experiments in immunity. He took swabs from the noses of patients and rubbed them over the nasal mucous membrane of infants under five months. Subsequent exposure in some infants who had reached a susceptible age, and reinoculation of others by the same method, proved them immune.

Prevention.

The prevention of measles is one of the most difficult of all health problems. This is mainly due to three facts:

1. The disease is extremely contagious.

2. It may be transmitted in the preeruptive stage.

3. The General public, and even physicians, discount its great importance.

As with other diseases notification of all cases is of prime importance. To secure complete and early notification the cooperation of the public is needed. Before this can be secured there must be a campaign of education. As without the coöperation of an instructed public no progress is possible, so the prevention of measles depends mainly upon the public itself. After notification there must be isolation of

the patient, and quarantine of susceptible exposures. Isolation in measles need not persist longer than ten days, if all acute symptoms have subsided before that period elapses. Quarantine of exposures should perist for two weeks. Concurrent disinfection should be directed towards the destruction of all discharges of the mouth and nose. Terminal disinfection is unnecessary because the virus of measles has little resistance and dies rapidly after leaving the patient. This is in accord with our knowledge that direct contact with a case is necessary to contract the disease.

The law of Ohio gives to local boards of health the power to quarantine cases of measles. Unfortunately, this is not required, but left optional. The State Department of Health has prepared a model regulation which local boards of health should adopt.

"For the patient. Isolation until recovery is complete, provided that such isolation shall not cease before ten days have elapsed from the occurrence of the disease.

"For exposed persons. Quarantine of children for a period of fourteen days from the date of last exposure to the disease.”

This regulation, or a similar one, should be adopted by all local boards of health, and vigorously enforced.

Other measures of prevention consist in securing the coöperation of the public, school teachers, physicians, and the use of school supervisors. The public health nurse is an invaluable aid in the prevention of measles. În fact, the public health nurse is of value in all preventable diseases, and particularly when instruction of the public is needed.

As far as schools are concerned, an epidemic of mealses may require their closing for two weeks. If at the end of that time the disease continues to spread, school may be reopened, as it is evident that factors other than the congregation of pupils is responsible for the spread. When the school is first exposed, it should not be closed until the lapse of a week, and then discontinued for two weeks. A better plan is to have all pupils examined as they enter school in the morning, and all children with any symptoms of cold, such as cough, infection of the eyes, sore throat, running at the nose, etc., excluded. This will accomplish what is most needed; that is, the isolation of all cases in the preëruptive stage.

Finally, the prevention of measles, while extremely difficult, offers large rewards and should be attempted in every health district. If the spread of measles is retarded, many fatalities in young children, and many cases of pneumonia will be avoided. It is probable that the tuberculosis death rate will also be lowered. These desirable results will accompany a reduction in economic losses from lack of school attendance, and the death of a considerable number of children. from some of the less common complications. Education of the public is a prime factor in the prevention of measles. Few cases of measles will die if properly treated.

The following facts should be kept clearly in mind:

(1) That measles causes about twice as many deaths every year in Ohio as scarlet fever, and more than twice as many as infantile paralysis.

(2) That the case-fatality rate is very high under five and very low over ten years of age; as high as 25 per cent in the very young, and less than 1 per cent in older persons.

(3) That it is very important to postpone infection until after ten years

of age.

(4) That the disease is spread by the discharges of the mouth and nose only during the febrile period and mainly in the pre-eruptive stage.

(5) That few cases of measles which are properly treated die.

(6) That the public must be instructed in regard to the dangers, and the means of transmission of measles.

(7) That physical supervision of the pupils is the best method of dealing with an outbreak of measles in school.

(8) That early isolation is the best means of preventing the spread of measles.

(9) That measles predisposes to pulmonary tuberculosis.

(10) That local boards of health have the power, under the law, to enforce precautionary measures.

(11) That when precautions are not taken, the local health department is responsible for a large amount of preventable sickness and death.

HIGH COST OF FOOD MAY CAUSE MORE PELLAGRA.

That there may be an increase in pellagra during the coming year on account of the rise in the cost of food-stuffs is the fear expressed in a statement issued by the U. S. Public Health Service. As a result of government researches it was found that pellagra is produced by an insufficient, poorly-balanced diet and that it can both be prevented and cured by the use of food containing elements in the proportion required by the body. The application of this knowledge greatly reduced pellagra in 1916 as compared with previous years. This reduction is believed by experts of the Public Health Service to have been due to improved economic conditions which enabled wageearners to provide themselves with a better and more varied diet and to a wider dissemination of the knowledge of how the disease may be prevented. It is feared, however, that pellagra may increase in 1917 by reason of an increase in food cost out of proportion to the prosperity now enjoyed by this country. The great rise in the cost of forage, particularly cotton seed meal and hulls, is causing the people in many localities to sell their cows and thus there is danger that they will deprive themselves of milk, one of the most valuable pellagra preventing foods. The high cost of living has further served to bring about a reduction in many families in the amount of meat, eggs, beans and peas consumed, all of which are pellagra prophylactics. In effecting economies of this nature the general public should bear in mind the importance of a properly balanced diet and refrain from excluding, if possible, such valuable disease preventing foods. It is believed that unless this is done there will be a greater incidence of pellagra next spring.