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city hall, as customary. Never has such wholesale vaccination been accomplished: 200,000 vaccinations in a few months. The November, 1922, cases—252 with 92 deaths dropped abruptly to 82 cases and 22 deaths, in December. In 1923 there were only 90 cases in the state; 45 cases in Denver, 13 of those during the first three months of the year. The last death was in March, 1923. In 1924 there were six mild cases in two families, both imported. One woman just returned two weeks from a visit in Kentucky came down with a few "pimples." The husband and child had no vaccination scars, so were vaccinated and quarantined in with the case. The child promptly came down with smallpox, while the husband, a few days before quarantine was to be lifted after about three weeks, had an attack diagnosed by the physician as flu, but which we felt might be an unusual kind of flu, and so postponed lifting of the quarantine for a few days. He soon proved himself a beautiful case of smallpox.

The other case was a child direct from St. Louis, come to spend the summer with some relatives, giving smallpox to two little cousins. The cases were so mild that the children were at large some days before they were reported as cases of possible communicable disease. One small child was reported to have bought candy at the corner store with pennies she had scratched "bumps on her with." The neighborhood was canvassed for unvaccinated children and contacts, and none found. There were no further cases.

To date, 1925, there has been no smallpox. At present we have no hospital for isolation of smallpox, having discarded the old one.

Practically our entire school population has good, recent vaccination scars. Each fall a large number of new residents and some kindergarteners are vaccinated, about 8,000 this year.

It is easy now to enforce vaccination in the few requiring it, as no organized opposition is met. The conscientious objectors were forced to be vaccinated during the emergency, and as it is over now, are indifferent to the occasional protest of the other fellow. As long as the health board quietly does its duty, year in and year out, not allowing itself to drift along a few years without enforcing vaccination, it isn't likely that heated argument will be started, with the consequent stimulation of the anti-vaccinationist.

THE SMALLPOX PROBLEM IN THE WESTERN STATES

L. B. Gloyne, M.D., Commissioner of Health,

Kansas City, Kansas

In this paper the discussion will be limited to certain phases of the smallpox problem in Kansas, Missouri, and Minnesota. All figures that I have been able to obtain indicate that smallpox in these communities is becoming greater each year.

We have a problem-in reality an increasing problem. The smallpox prob

lem is a vaccination problem. Smallpox has never been controlled by quarantine, and in my opinion it never will, so let us turn our attention to vaccination.

Objections to law requiring vaccination only in time of an epidemic.—The three states mentioned do not have a law requiring the vaccination of school children, except in time of an epidemic. Minnesota had a compulsory vaccination law, but it was repealed in 1903. One will readily admit that a law requiring vaccination during an epidemic is better than no law at all. But such a law is a compromise with the anti-vaccinationists, and is a compromise that leads to a great deal of difficulty, for the following reasons: first, such a law, on the face of it, admits that we must sacrifice a number of lives from an entirely preventable disease before the law becomes operative; second, such a law provides that someone must declare that an epidemic exists; third, such a law does not define the number of cases that constitute an epidemic. Almost all health officers, because of their interest in humanity, feel that when there is a marked increase in the number, and usually in the severity, of cases, an epidemic should be declared; fourth, when such a law becomes operative and the community affected really enters into the spirit of the law, it throws the community into more or less of a chaos, as large numbers of people become scared (as in fact they really should) and want to be vaccinated at the same time; fifth, such a system causes a great financial loss to the business men of the community; sixth, the school system is paralyzed during such a period; seventh, because of the large amount of excitement during such a period, any thing that has to do with smallpox is a newspaper story. Thus the anti-vaccinationists get more publicity at that time than at any other.

The bureau's conclusions and recommendations.-I believe the bureau's con clusions and recommendations shed so much light on the smallpox problem in the western states that they should be given here verbatim:

Our investigation of the smallpox epidemic covered, first, the vital statistics of the health department, records of contagious cases, hospital data, etc.; second, the action of the Public Health Committee of the Jackson County Medical Society in declaring the existence of an epidemic of smallpox; and, third, the unfavorable publicity which followed in the press, through placards, the bulletin to school principals, items which were copied by the daily and weekly country papers, and in the agricultural and trade press throughout the territory.

As a result of this thorough and impartial investigation we are forced to the conclusion that the third factor, the publicity (which we believe the press carried in good faith) was not justified by the facts shown to exist in the health situation of the city at that time, even in face of the virulent type of the disease. We wish to emphasize our belief in and insistence upon thorough precautionary measures of all kinds to protect our citizens against the inception and spread of contagious disease. We believe in the scientific detection and regulation of disease.

However, we do not believe in epidemics which can be started or stopped by publicity methods alone. We feel the smallpox "epidemic" of last fall had some of the earmarks of such a scare, and that it could have been nipped in the bud and the irreparable damage to business and the city's reputation averted.

To assist in preventing a recurrence of the events of last November, we make the following recommendation:

That the hospital and health board of Kansas City, Missouri, should add to its cooperative agencies an advisory committee of carefully selected business executives drawn from various

lines of business for counsel in emergencies which affect the public health and welfare. This advisory committee, of a number not to be unwieldy, to have equal advisory powers with the medical authorities, upon whom the hospital and health board rely for advice. By this means the analysis and recommendations of the health experts on the board may be tempered by the judgment of business executives accustomed to handling big problems of a business and civic nature.

Such counsel, coming on the one hand from expert business executives, would increase the efficiency of the hospital and health board. Such an organization could do more to ferret out and curb disease, prevent the spread of epidemics, keep at a high level the work of the health and sanitary departments, and in general protect health, life, and property, than a body of medical specialists working alone with the hospital and health board. We believe such a plan of cooperation between health and business officials could be set up without the necessity of any legal or political machinery.

Meanwhile the bureau will maintain a watchful attitude over all publicity concerning health conditions that may appear in the press or other publicity channels, and will endeavor to see to it that a prompt investigation is made of any alleged "epidemic." With the thought that the public health is first, and business second, the bureau wishes to avert any damage to the second inconsistent with the greatest benefit to the first.

In this endeavor we desire the cooperation of civic officials, medical authorities, business institutions, and the press of the city, as well as the general public, in a plan to make Kansas City not only a good place in which to live, but in which to do business.

Problems in the Twin Cities.-I have gone somewhat into detail on the Kansas City situation because of my first-hand contact with it and because I consider the whole situation rather typical of the western states.

The Twin Cities, Minneapolis and St. Paul, have been having quite an experience with smallpox during the last year (May 1, 1924, to April 30, 1925). During that time there were 1,501 cases with 378 deaths. The Minnesota law is similar to the Kansas and the Missouri law. It is interesting to note that the same problems have been met there. The first problem, which is to decide when an epidemic really exists, was a real one. The Minneapolis papers carried an official communication that "no epidemic exists" at a time when 333 persons had needlessly lost their lives in six months.

Suggestions. It is fortunate for the writer that the subject of this paper is the smallpox problem in western states, and not the solution of the smallpox problem in western states. I feel entirely unable to suggest a solution to this complex and difficult problem. I do, however, have a few suggestions to make. As I have said that I consider the smallpox problem a vaccination problem, I might go on and say that I consider the vaccination problem mainly an educational problem.

One may ask who is responsible for the present situation, those persons who are leaders in health work, or the general public? My answer is that both are more or less responsible. It is impossible in a democratic form of government to make any law, or enforce it after it is made, unless the general public is thoroughly convinced of the need of the law. Where, I believe, we as health workers have fallen down is in allowing our population to grow up without the proper knowledge of the ravages of smallpox.

We cannot expect the general public, the majority of whom have never seen a real case of smallpox, to be in favor of universal vaccination unless special methods are used to show them the dangers of smallpox. In our public schools we teach patriotism by studying the history of the wars through which our country has passed. When matters of national military defense come up, the public remembers the history of past wars, remembers the pictures of the battles which were shown them when they were school children; and even if they have never been in a war, the vast majority have a spirit of national defense instilled in their hearts. But what school child is there, who, when the question of national smallpox defense comes up, can recall any pictures of persons losing their lives because of failure to be vaccinated? What child is there who knows the losses sustained by unvaccinated communities, or the effect of smallpox on the history of the world before the time of vaccination? I believe that some such educational work will have to be done before there will be any marked improvement in our present laws.

Conclusion. The smallpox problem is becoming worse instead of better in western states. The law requiring vaccination only in time of epidemics is unsatisfactory. It causes large numbers of persons to lose their lives before it can be put into operation. It causes an inestimable financial loss to the business interests in the community affected, large financial loss to taxpayers, and it causes large numbers of persons to be vaccinated in a hurry and under conditions not as favorable as when vaccination is carried on systematically each year. The problem is a complex one, but one suggestion offered is the better and more thorough education of the school children of this country as to the past history of smallpox and of vaccination.

THE SMALLPOX PROBLEM IN THE WESTERN STATES

A. H. Flickwir, M.D., City Health Officer, Houston, Texas

Texas, in which the city of Houston is located, is really in the Southwest rather than the West, and Houston, being rather a short distance from the Gulf, is perhaps more southern than western; therefore perhaps our problems may be somewhat different from those of the other health officers who have spoken regarding the smallpox situation. No doubt the mortality is much lower in Texas, on account of the mild climate, than it is in the other states; also, it is well known that smallpox is usually more prevalent in cold weather than in the summertime and of course, being in a semitropical climate, no doubt some weight must be given to that in summing up the general situation, both morbidity and mortality, as there is not as much crowding as in some states, there being few tenements.

The great state of Texas also, as you know, has a border adjoining Mexico of over 1,000 miles in length, with immigration both legitimate and illegitimate

going on at all times. Then for the past twenty years there has been a great deal of immigration to our state from the North, the East, and the Middle West. Sometimes great train loads of home seekers come in daily, therefore you can realize the probability of smallpox coming along, especially as the immigration is generally in the wintertime.

Another condition in Texas which has a bearing on the situation in reference to smallpox as well as other diseases is the large colored population. We never have an epidemic of smallpox but that the negroes are usually in the majority, the reason being that they are not as apt to be protected by vaccination as much as the whites, a great many of them living in the rural districts outside of the city limits and coming into the city only to work or trade. And on the other hand a great many of our town negroes go to the oil fields or railroad grading camps, lumber mills, etc., to work, and are there thrown with an unvaccinated group of people again. Really, except for the above reasons, our smallpox problem is not much different from that of other states, although the state is so very large and the distances in the country districts are so great that there is a lack of country doctors, which naturally leaves a rather large unvaccinated rural population. Most of the large cities of Texas, including my own city of Houston, have a compulsory vaccination law for school children. Houston was among the first in the South to institute the same, and although it has been attacked several times by anti-vaccinationists and others it is still in force and has proved to be very valuable in checking the spread of this disease.

The population of Houston has been increasing very rapidly in the last twenty years, and in the last five years it has almost doubled in size, but still there were not as many cases of smallpox in 1924 as there were in 1904. Our highest point in the past twenty years was in 1907, when there were 194 cases, and the lowest in 1923, during which year we had only 6 cases. In 1924 we had a renewal of smallpox, having 86 cases, and since the first of January, this year, we have had about a like amount. During the past twenty years there were 1,215 cases of smallpox in Houston with only 33 deaths, which is indeed a very low mortality. We have not had a death since 1922, when there was only one.

Personally, I have seen a great many cases of smallpox since my graduation in medicine in 1901, but I have never seen a case of smallpox in a person with a good vaccination scar, regardless of how old the scar was. However, that is only my personal experience. I have seen patients who had chicken pox that had been vaccinated and diagnosed as smallpox, but no true smallpox in successfully vaccinated individuals.

In the schools of Houston in the last four years there have been over 20,000 successful vaccinations. In evidence of the success of vaccination in preventing smallpox, I wish to state that in 1924, and so far in 1925, there have been fifty school children in homes in which smallpox was present, and as they had all been properly vaccinated, not one of them developed the disease.

Now what is the smallpox problem? One of prevention, of course. And

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