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 imporTo 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.

THE DISTRICT TUBERCULOSIS HOSPITAL: ITS VALUE TO THE COMMUNITY.*

J. HARRIS, M. D.,

Ohio State Sanatorium, Mt. Vernon.

Tuberculosis, whether viewed from an economic, social, or medical standpoint, is of greater importance than any other disease that afflicts our people. It is responsible for approximately 7,000 deaths annually in the state of Ohio. Consider what this means; a city half the size of Chillicothe wiped out every year. And of these 7,000 deaths, Ross county contributes its full quota. One death out of every ten is due to tuberculosis. One-third of all deaths between the ages of fifteen and fifty are due to tuberculosis; and this is the age when the life of the individual is of the greatest economic value, and his death of the greatest loss to the community. Apart from the economic loss, think of the untold misery and suffering that these deaths leave in their wake.

What is the community doing to stop the suffering and to limit the economic loss that is due to tuberculosis; a preventable disease?

The community may be looked upon as a group of families, and each family as a group of individuals. As the well and competent members of a family should care for the sick and incompetent members, so the responsibilities of the community are no less than the responsibilities of the family. The control of tuberculosis is in a large measure a local problem, and should be taken care of by local agencies such as the county or district hospital.

In 1908 experts from all over the world met at Washington, D. C., at the International Tuberculosis Congress to discuss the problem of the control of tuberculosis. The congress placed itself on record in favor of this proposition-the most important feature in the movement to control tuberculosis must be hospital care for the advanced cases, and sanatorium care for the early ones. It was further emphasized that the two requisites could be effectively provided only by locating institutions near enough to the homes of the patients so that they would readily avail themselves of their benefits.

These recommendations have appealed so strongly to tuberculosis workers throughout the country, that we are now in the midst of the District Tuberculosis Hospital movement. This movement is growing, but it will require some years before its results become fully apparent. The establishment, however, of an ever-increasing number of local hospitals for the treatment of tuberculosis indicates the general realization of their necessity.

Ohio, ever alert to make use of the most desirable and most practical methods of solving its problems, has followed the lead of New York and other states and has passed laws permitting the local communities to organize their crusade against tuberculosis by the erection.

* Read by invitation before Ross County Academy of Medicine, December 5, 1916.

and maintenance of district hospitals, under the supervision of the State Board of Health. Such institutions are for the protection of public health, and are in no sense a charity.

Under these laws thirty-six counties have availed themselves of this opportunity and have erected or are helping to maintain hospitals for the treatment of early cases and for the care and segregation of advanced cases. In the brief period since their establishment, these hospitals have fully justified their existence.

The records of the Ohio State Sanatorium demonstrate the necessity for a local tuberculosis hospital, as seventy-five patients have been taken care of from the counties in this district. We must remember that the state sanatorium should only receive incipient cases, and the medical profession sees five or six moderately advanced or advanced cases to every early case of tuberculosis. Most of the cases that are too ill for treatment at the sanatorium remain at home, usually inadequately cared for, and a prolific source of infection to family and community.

That this spread of infection is a matter of concern to the community is shown by the report of Dr. H. G. Lampson, who recently investigated the spread of infection in certain tuberculous families in five counties in Minnesota. His conclusions are as follows:

79% of the individuals fully exposed for a long period of time to open cases become infected.

28% partially exposed or exposed for a short period become infected.

8% become infected from casual exposure such as everyone

encounters.

To control the spread of tuberculosis, the community must protect itself from foci of infection in its midst. In a recent investigation made in Cincinnati by the United States Public Health Service with the object of determining the causes of the high death rate from tuberculosis, one of the conclusions was that "inadequate segregation of advanced cases is an important factor in the high death-rate.”

Thus we see that the best means for controlling tuberculosis is segregation, and the concrete expression of the means for segregation is the county or district hospital. The superiority of the institutional treatment of tuberculosis over treatment at home has been definitely established. Without proper institutional facilities, the tuberculosis defenses of a community are in complete, and the local end of the campaign lacks one of its strongest weapons.

The value of the tuberculosis hospital to the community is threefold:

Ist: It returns the early cases to working capacity.

2nd: It is the educational center by means of which helpful knowledge in the anti-tuberculosis campaign is imparted to the community.

3rd: By segregation, it removes from the community active foci of infection.

The community is interested in the anti-tuberculosis movement for humanitarian reasons, and because tuberculosis accounts for a