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No. 2077, S. K., jr., Hawaiian, age 11, single, schoolboy. Admitted 7/13/21; type, nodular; B. lepre present; duration, 2 months before admission. First symptom, nodules in ears; last bacteriological examination, 6/19/22, B. lepra present.

Aug. 10: No vaccination scar.
Aug. 23: Vaccination on left arm.
Aug. 26: No change at site of vaccination.
Aug. 28: Vaccination apparently unsuccessful.
Aug. 30: Arm normal; no “take.”
Sept. 11: No change seen in this patient's leprous condition since he was vaccinated.

No. 2080, E. L., Hawaiian, female, age 22, single, no occupation. First admitted 2/8/19; type, nodular; B. lepra present; duration, 3 years prior to first admission. First symptom, spots on face. Paroled March 5, 1921. Readmitted July 19, 1921, with spots on face and B. lepra present in these lesions. Last bacteriological examination, 6/19/21, B. lepræ not found.

Aug. 10: No vaccination scar.
Aug. 23: Vaccinated on left arm.
Aug. 25: Site of vaccination slightly reddened.
Aug. 26: Slight vesiculation at site of vaccination.
Aug. 28: Typical “take;" vesicles well marked.
Aug. 31: Complains of tenderness in left axilla.
Sept. 3: Tenderness less; no leprous eruption has yet appeared.
Sept. 5: Vaccination wound healing normally.
Sept. 7: Healing proceeding rapidly.
Sept. 11: Healing nearly complete.

No. 2084, J. K., IIawaiian, female, age 30, married, housewife. First admitted, 8/8/19; type, nodular; B. lepra present; duration, 5 years prior to first admission. First symptom, swelling all over body. Paroled, 3/5/21. Readmitted, 7/19/21, with a general eruption; B. lepra present. Last bacteriological examination, 6/6/22, B. lepræ' present. During her last year of residence in the hospital, she has been subject to frequent outbreaks of leprous eruptions, one of the manifestations of the disease being the development of deep-seated indurations in the breast which subside as the eruption fades.

Aug. 10: No vaccination scar.
Aug. 23: Vaccinated on left arm. No active leprous eruption present.
Aug. 26: Vesiculation at site of vaccination.
Aug. 28: Arm shows a typical "take."

Aug. 30: General eruption on face, body, and extremities, with chilliness and lever and anorexia. Spots are extremely tender.

Aug. 31: Eruption more pronounced. Both breasts contain large indurated lumps.
Sept. 3: Eruption practically unchanged, but constitutional symptoms abating.
Sept. 5: Arm is healing normally. The eruption is beginning to decline.
Sept. 7: Improving rapidly; breasts are better, but still tender and contain lumps.
Sept. 9: Improving rapidly.

Sept. 11: Has shown remarkable improvement in past two days. Snip from forehead positive for B. lepræ.

No. 2089, M. P., Filipino, age 26, single, laborer, in Hawaii 9 years. Admitted 8/8/21; type, nodular; duration, 6 months prior to admission. First symptom, enlargement of nose; B. lepra present. Last bacteriological examination, 7/7/22; B. lepra present.

Aug. 10: No vaccination scar found.
Aug. 23: Vaccinated on left arm.
Aug. 26: Site of vaccination slightly reddened.
Aug. 28: Arm normal; no “take."
Sept. 11: No change seen in patient's condition since admission.

No. 2093, R. C., Hawaiian, female, age 36, married, housewife. Admitted 8/25/21; type, anesthetic; B. lepra present; duration unknown; first symptoms unknown; last bacteriological examination, 7/6/22; B. lepra present.

Aug. 10: No vaccination ecar.
Aug. 23: Vaccinated on left arm.

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Aug. 26: Vesicle present, but has been scratched open.
Aug. 30: Typical take”; complains of pain in axilla.
Aug. 31: Remains in bed on account of pain in axilla. Feeling normal otherwise.
Sept.'5: Arm is healing.

Sept. 7: Healing progressing normally. No eruption or exacerbation of leprosy symptoms has been noted.

Sept. 11: Healing nearly completed.

No. 2108, W. K., Hawaiian, male, age 7. Admitted 10/3/21; type, anesthetic; B. lepra not found; duration, 6 months before admission. First symptoms. swelling of hand; last bacteriological examination, 6'19/22; B. lepra not found.

Aug. 10: No vaccination scar.
Aug. 23: Vaccinated on left arm.
Aug. 26: Result of vaccination doubtful.
Aug. 28: Slight vesiculation present.
Aug. 30: Typical "take.
Sept. 5: Arm healing rapidly. Patient has shown no eruption or other evidence
of leprosy since vaccinated. He has, however, become clear of all lesions present on
admission and will probably be paroled in the near future.

Sept. 11; Vaccination healed.

No. 2111, A. H. T., part Hawaiian, female, age 27, single, no occupation. Admitted 107:21; type, nodular; B. lepra present; duration, 5 years before admission. First symptom, white spots on arms; last bacteriological examination, 6/9/22; B. lepræ present.

Aug. 10: No vaccination scar.
Aug. 23: Vaccinated on left arm.
Aug. 26: Vesiculation at site of vaccination.
Aug. 28: Vesicle well developed and becoming pustular.

Aug. 30: Has an exacerbation of her leprous lesions on both thighs, the spots being large, red, elevated, and tender upon pressure.

Aug. 31: The eruption has become general and is showing on all the extremities, and, to a less degree, on the face. Patient confined to bed. Complains of chilliness and fever.

Sept. 3: Eruption has remained practically stationary since last note.
Sept. 5: The eruption seems to be declining though she still has some fever.
Sept. 7: The rash is subsiding, but the afternoon temperature remains abnormal.
Sept. 9: Eruption is fading slowly. Arm healing satisfactorily.

Sept. 11: Much improvement in past two days. Snip from two of the recently erupted spots negative, though one doubtful field was found.

Sept. 13: Another bacteriological examination of the site of recent eruption shows a few typical lepra bacilli.

No. 2116, M. T., Japanese, female, age 7, single, born in Hawaii. Admitted 10/15;21; type, nodular; B. lepra present; duration, one year prior to admission. First symptom, red spots on cheek; last bacteriological examination, 6'19:22; B. lepræ present.

Aug. 10: No vaccination scar.
Aug. 23: Vaccinated on left arm.
Aug. 26: Slight vesiculation at site of vaccination.
Aug. 28: Vesicle present.
Aug. 31: Running usual course of vaccination.
Sept. 5: Shows evidence of beginning healing.
Sept. 7: Healing progressing normally; no eruption has been observed.
Sept. 11: Healing of vaccination sore is practically complete.

No. 2117, N. P., Hawaiian, male, age 14, single, no occupation. First admission,
11/24/18; type, nodular; B. lepra present; duration, one year prior to admission.
First symptom, nodules on face; paroled 3/5/21. Readmitted 10/26'21; type, nodular;
B. lepre present; last bacteriological examination, 321, 22, B. lepræ not found.

Aug. 10: No vaccination scar.
Aug. 23: Vaccinated on left arm.
Aug. 25: Beginning vesiculation at site of vaccination.
Aug. 26: Vesiculation well marked.

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Aug. 31: A profuse, red, clevated tender rash has appeared on both arms and the face. Has some chilliness and fever and is confined to bed.

Sept. 3: Eruption a little more extensive to-day.

Sept. 5: The leprous eruption continues, being most severe on the face and forehead, where the original lesions were located.

Sept. 7: Eruption receding and patient feeling much better.
Sept. 9: Eruption has improved rapidly in past two days.

Sept. 11: Only faint traces of the eruption are seen. Arm nearly healed. Snip from forehead and cheeks positive for B. lepræ'.

No. 2127, E. K. L., part Hawaiian, age 17, female, single, no occupation. Examined 2'11/15 and declared "not a leper"; B. lepra not found. Symptoms at that time, leucoderma areas on face. Examined and declared a leper 4/17/19; type, anesthetic; B. lepra present. Duration, about seven years; symptoms, pink spots and areas on face, arms, and legs. Paroled 11/15/19; readmitted 11/28/21, B. lepra present. Last bacteriological examination 7/13/22, B. leprx present.

Aug. 10: No vaccination scar.
Aug. 23: Vaccinated on left arm.
Aug. 26: Vaccination site slightly reddened.
Aug. 28: Site of vaccination, showing typical vescicles.
Aug. 30: Following the usual course of vaccination. No complaints from patient.
Sept. 3: Has slight soreness in leit axilla.
Sept. 5: Vaccination wound healing.

Sept. 7: Healing nearly complete. No change has been noted in this patient's condition, nor has she complained of chilliness, fever, or any other symptom.

Sept. 11: Arm nearly healed.

No. 2129, C. 0. B., Korean, age 47, widower, laborer. Examined and declared leper 8/27/17; type, nodular; lepra bacilli present. First symptoms stated to be neuritis in legs five months previous to examination. Sent to Molokai 10/5/17; paroled from Molokai 11/5/20; readmitted to Kalihi 12/3/21, with many nodules on face, cars, body, and extremities. B. lepræ present.

Aug. 10: Shows no evidence of previous vaccination.
Aug. 23: Vaccinated on left arm.
Sept. 11: Arm healed.

No. 2146, N. K., Japanese, age 50, male, single, in Hawaii 25 years. Admitted 2/22; type, mixed; B. lepra present; duration, nine years prior to admission. First symptom, swelling of cheeks; last bacteriological examination 2/9/22, B. lepræ present.

Aug. 10: No vaccination scar.
Aug. 23: Vaccinated on left arm.
Aug. 26: Appears like a beginning "take."
Aug. 28: Vaccinated site normal; evidently not successful.
Sept. 5: Vaccination unsuccessful.

No. 2155, E. K., part Hawaiian, age 8, female, single, no occupation. Admitted 2, 23:22; type, anesthetic; B. lepræ not found; duration, about six months. First symptoms, swelling and contraction of fingers of left hand. Last bacteriological examination 7/8/22, B. lepræ not found.

Aug. 10: No vaccination scar present.
Aug. 23: Vaccinated on left arm.
Aug. 26: Slight vesiculation present.
Aug. 28: Typical vesicle present.
Aug. 31: Slightly tender in left axilla.
Sept. 5: Vaccination seems to be healing,
Sept. 7: Healing progressing normally: No eriiption seen at any time.
Sept. 11: Scab is off, leaving a rather deep ulcer.

No. 2168, H. K., Hawaiian, age 12, single, male, no occupation. Admitted 6:2:19; type, nodular; B. lepra present; duration, 1 year prior to admission; first symptom,

itching of hands and feet. Paroled 3/5/21. Readmitted 4/11/22; B. lepræ present;
type, mixed. Last bacteriological examination 4/11/22; B. lepra present.

Aug. 10: No vaccination scar.
Aug. 23: Vaccinated on left arm.
Aug. 26: Beginning vesiculation noticed.
Aug. 28: Typical "take.''
Aug. 31: Complains of feeling slightly indisposed and of soreness in left axilla.

Sept. 5: The vaccination is progressing nicely. To-day he shows a slight eruption on the face and forearm.

Sept. 6: Eruption is more pronounced, especially on face, being red, indurated, and tender.

Sept. 7: Eruption about the same as yesterday.
Sept. 9: Arm healing rapidly. Eruption has subsided.

Sept. 11: Only faint trace of the eruption can be made out. Snip from left forearm and right malar region, negative for B. lepræ.

No. 2191, P. M., Cuban-Filipino, age 37, male, single, laborer. Admitted 6/10/22; type, mixed; B. lepra present. In Hawaii 12 years; duration, 2 months. First symptom, red elevated spot on forehead. Last bacteriological examination 6/10/22, B. lepræ present.

Aug. 10: No vaccination scar.
Aug. 23: Vaccinated on left arm.
Aug. 25: Vaccinated site slightly reddened.
Aug. 28: Vaccination unsuccessful.

No. 2194, U. K., Ilawaiian, age 20, male, single, seaman. Admitted 6/24/22; type, mixed; B. lepræ present; duration 8 months. First symptom enlargement of ear. Last bacteriological examination 8/17/22, B. lepra present.

Aug. 10: No vaccination scar.
Aug. 23: Vaccinated on left arm.
Aug. 26: Site of vaccination slightly red and pufiy.
Aug. 28: Vesicle present.
Sept. 5: IIas run the usual course of vaccination,

Sept. 7: There is a slight leprous eruption on the back of the right leg. This seems to be a typical leprous outbreak, but is not severe and is delayed several days, as compared with the other cases. Until Aug. 30 this case received no chaulmoogra derivatives, but was treated with "oscol stibium,” a colloidal antimony preparation.

Sept. 9: The eruption is declining, showing a wrinkled surface and less color.

Sept. 11: Vaccination nearly healed. Eruption has subsided. Snips from erupted spots on leg show B. lepræ present.

Editor's Note: The following references to earlier work on the subject are of interest:

Morrow (Twentieth Century Practice of Medicine, Wm. Wood & Co., Vol XVIII, p. 503) says: “Hardy speaks of the good effects of an intercurrent attack of smallpox. Vaccination is sometimes said to exert an equally favorable influence. Beavan Rake particularly noted first swelling and then disappearance of the tubercles in patients whom he had vaccinated.”

Dock (Modern Medicine, Osler & McCrae, Lea & Febiger, Philadelphia and New York, Vol. I, p. 845) notes that vaccination has been thought to have a curative effect on several diseases, including leprosy.

The influence of smallpox on leprosy has been made the subject of several reports, as follows: 1769. Petersen, Jonas: Ashandling om den islandski Skjorbug. Soroe. p. 87. 1848. Daniellssen, D.-C., et Boeck, W.: Traité de la spédalskhed, ou éléphantiasis

des Grecs. Traduit de norwégien par Casson (de Nogaret). Paris. p. 113. 1875. Hardy, Alfred, et Labarraque, Edward: Lépre. In “Nouveau dictionnaire

de médecine et de chirurgie pratiques.” Jaccoud, ed. Paris, Bailliere. vol. 20,

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p. 384.

PRINCIPAL CAUSES OF DEATH: 1921.

The Department of Commerce announces that the compilations made by the Bureau of the Census show that 1,032,009 deaths occurred in 1921 within the death registration area of continental United States, representing a death rate of 11.6 per 1,000 population as compared with 13.1 in 1920. The rate for 1921 is the lowest rate recorded in any year since the beginning of the annual compilations in 1900.

The death registration area (exclusive of the Territory of Hawaii) in 1921 comprised 34 States, the District of Columbia, and 16 cities in nonregistration States, with a total estimated population on July 1 of 88,667,602, or 82.2 per cent of the estimated population of the United States.

The death rate from cancer increased from 83.4 per 100,000 in 1920 to 86 in 1921. Some of the other diseases for which the rates increased are diphtheria, typhoid fever, appendicitis, scarlet fever, diabetes, and puerperal fever. The fatalities caused by automobile accidents and injuries show an increase from 10.4 per 100,000 in 1920 to 11.5 in 1921.

A marked decrease is shown in the death rate from tuberculosis, which was 99.4 in 1921 as compared with 114.2 in 1920; also in the death rate from influenza and pneumonia (all forms) which was 99.8 in 1921 against 208.3 in 1920. The rates for measles, bronchitis, nephritis, whooping cough, heart disease, and diarrhea and enteritis also declined. Number of deaths and death rates by leading causes for the death registration area in con

tinental United States, 1920 and 1921, together with the percentage which cach cause or group of causes contributed to the total.

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All causes..

1,032,009 1,142,558 Heart diseases 1

130, 351 131,004 Influenza and pneumonia (all forms)

8R, 150

182.205 Tuberculosis (all forms)..

88, 135 99, 916 Cancer and other malignant tumors.

76, 274 72,931 Nephritis...

75, 696

78,192 External causes (suicide and homicide excepted)....

60, 396 62, 192 Automobile accidents and injuries.

10,168 9, 103 Accidental falls...

10,102 10,323 Accidental drowning

6,489 4,977 Burns (conflagration excepted).

5,320

6,645 Railroad accidents and injuries.

5,297 6, 426 Accidental shooting...

2,316 2,262 Injuries by vehicles other than railroad cars, street cars, and automobiles..

1, 821 1,695 Mine accidents and injuries..

1,777

2,171 Machinery accidents and injuries.

1,573 2, 153 Street-car accidents and injuries.

1, 160 1,746 Effects of heat other than burns.

946

270 Other external causes..

13,385 14,713 i Includes endocarditis and myocarditis (acute).

Excludes capillary bronchitis in 1920. 3 Less than one-tenth or 1 per cent.

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