such children have always a doubtful future, as they are ready victims to intercurrent maladies, and naturally their chief danger is that the nature of their disease is not realized soon enough. It has been estimated that 50 per cent of syphilitic children die in their first year, 25 per cent in the second year, leaving 25 per cent to reach maturity.

If a married man harbors a gonococcus infection, his wife is in imminent peril of invalidism and severe surgical mutilation, and his children may be unfortunate enough to become infected at birth and to lose their sight.

What a panorama of sickness, destitution, subnormality, and dependency do these facts reveal! This picture of the familial aspect of venereal disease is not overdrawn. While it is true that the majority of male victims contract their disease in youth and before marriage, the tendency of venereal disease to lie dormant but still be contagious is its most harmful characteristic. As has been pointed out by authoritative writers, men mostly contract venereal disease before marriage-women after marriage. And not unusually the husband as well as the wife is unaware of the real nature of the domestic tragedy that so often results as a sequel to an infection long since forgotten or disregarded. With this in mind, and considering also that syphilis may be transmitted to the offspring, we can appreciate the fact that a considerable proportion of victims do not contract their infection through illicit sex relations. So-called "innocent infections" are by no means rare.

The venereal diseases are among our chief contributors to the hospital and the dispensary, to institutions for mentally diseased, to the orphan asylum, the poorhouse, the home for defective children, and to other institutions, and are the principal cause of sterile marriages. Syphilis is one of the chief causes of death.

Here is an antagonist not to be overcome by a moralistic, or rather a pietistic, attitude, nor by ignorance, silence, and concealment, but by active attack, in which sympathy and understanding are necessary weapons on every battle front that the social hygiene campaign has developed.

The abatement of prostitution, the spread of information to the public, the provision of facilities for diagnosis and treatment, careful examination of subnormal children, routine and thorough examination of every prospective mother, followup on members of the family of venereal disease patients, all are types of activity against venereal disease. Most important of all is the instillation of high ideals in childhood, and education through carefully prepared and selected material. Routine examination of prospective mothers offers the opportunity of stamping out congenital infection. A series of cases at Johns Hopkins Hospital demonstrated that if infected mothers were treated before the sixth month, a normal child was practically always assured. If treatment was instituted at a later date, favorable results were not so certain.

The social worker has an important part to play in venereal disease control as has any other agent. Scientific research, clinical facilities, the elaboration of

therapeutic remedies, the standardization of treatment, are of little avail if we cannot reach the persons affected. Most victims will apply for treatment when the acute stage is giving them actual discomfort. But treatment is long, tedious, and calls for self-control and active cooperation on the part of the physician, the patient, and the social worker. Translated in working terms, this means that beside facilities for diagnosis and treatment there must be machinery to follow up the patient and induce him to keep coming for treatment, and perhaps put pressure on him if he is unwilling. Constant stimulation, supervision, and encouragement are needed. This demands a high degree of organization, with public health nurses and hospital social service workers working in harmony with the clinics and the public health authorities. Even then we have only just begun. The families of patients must be reached, the wife and children protected and examined as to their possible infection. Those infected must also be directed to the clinics or private physician for treatment, and in all this the patient and his interests must be safeguarded. More than organization is needed here; experience, tact, and sympathetic approach are indispensable.

The family case worker, the social worker in the juvenile court, and those who deal with the various phases of delinquency and of subnormality among children should ever be mindful of the rôle of venereal disease in contributing to their problems.

To sum up, we might say that social work in the venereal disease field calls for sanity and common sense-the avoidance of the spectacular and the bizarre. In many respects the social hygiene campaign stands where the tuberculosis campaign did some ten or fifteen years ago. In tuberculosis work we now accept as routine procedures which were looked upon as doubtful or dangerous when they were first proposed. So it is with our efforts to bring venereal disease out into the open and rob it of the terrors that go with secrecy and ignorance. The reporting of cases of venereal disease to the health authorities is one of the most vexing problems that constantly face us. It is gradually yielding to intelligent pressure and to educational methods.

The Charity Organization Society of New York has just published a pamphlet on The Social Worker's Approach to the Problem of Venereal Disease, that I commend to you wholeheartedly. It contains a foreword by Dr. Stokes which expresses a fact that is not sufficiently appreciated:

It seems to me that it is always worth while to emphasize a function of the social worker in connection with venereal disease which is not often thought of. The social worker and the followup system in dealing with venereal disease are part of medical research; in fact, the importance of observation and of the ability to follow the patient over a period of years is more vital in the problem of syphilis than in any other aspect of medicine. To the extent that the case worker and the social service assistant make this possible for the medical man, they are a necessary part of the machinery of clinical research. While the humanistic and spiritually constructive aspects of their work are of extreme importance, they should not exclude from consideration the very great contribution which the social worker can and does make to scientific medicine.

Above all, the social worker has the opportunity-the responsibility-of spreading the gospel of truth, of sane thinking, and of sympathetic treatment.

THE SMALLPOX PROBLEM IN THE WEST

Ethel Humphrey, M.D., Health Officer, Denver

The smallpox problem in the West is one that needs the serious attention of every health official. Susceptible persons plus exposure equals an epidemic as certainly as two and two make four. Vaccination and revaccination is a sure preventive, yet the age-old human characteristic is the necessity of learning by bitter experience. Until the wolves are actually upon them, sufficient support cannot be aroused to give needed authority for forcing a simple protective procedure. They fancy themselves secure.

With the step backward of some of the states and cities of the West in repealing their compulsory school vaccination law, the effort of their health officer is materially hampered. It falls to his lot eternally to warn, coax, cajole, and plead with those he serves to protect themselves and their children. He does his best through educational methods, lectures, health bulletins, radio talks, and other avenues for propagating scientific proof of the necessity for vaccination against preventable disease. Many approached are thoughtless or careless and do not heed, mentally promise to attend to it "sometime"; others, because of the effective propaganda of the anti-vaccinationist, actively fight any attempt to protect them. The just and well-merited penalty for neglect is severe; the inevitable result in time is a virulent epidemic accompanied by death and disfigurement, with its attending train of sorrow and discomfort, and an individual financial loss due to quarantine of exposed or sick wage-earners and large public expenditure for doctors, nurses, quarantine officers, vaccination stations, and other emergency relief- all unnecessary if everyone could but quietly and routinely be protected by vaccination.

Only wholesale vaccination of the unprotected population can save a yearly increase in cases and deaths, a conflagration as the dry fuel accumulates. In the face of figures showing a generalized increase in case incidence and death we postpone taking up the fight, too tolerant of unscientific error, the propaganda of the anti-vaccinationist.

There was a fluctuation of total cases in forty-four states and territories during the four years from 1913 to 1917, there being an average of about 28,611 cases a year. During the next five years the average jumped to over 80,086 a year; of these, 4,005, from 1913 to 1917, were in eight western states, and from 1917 to 1922, 13,731, the western states in this incidence meaning Montana, Colorado, Arizona, Utah, Nevada, Washington, Oregon, and California. The number of cases mounted rapidly in some of the western states, i.e., California, Oregon, and Colorado, but Montana, Arizona, Nevada, New Mexico had no such alarming increase.

In 1922 there is again a decided drop in case incidence from a total of 108,904 cases in forty-four states and territories in 1921 to 34,169 in 1922, and a drop in ten western states (adding Idaho and New Mexico) from 20,596 to 8,029 in 1922.

In 1923 total cases only slightly decreased, from 34,169 to 30,313, and in 1924 increased again over 52,000 cases. With this increase in number of cases we have an increased virulence, with a greater death incident than in 1922, when hemorrhage smallpox was doing its worst, and three times as many deaths as in 1923.

The drop in cases in 1923, therefore, was not an indication that the prevalence of smallpox is over, but rather the 1921 and 1922 scare had brought about an increase in vaccination in 1923. With the drop in cases and deaths, vigilance slackened, in the belief that the worst was over. The year 1924, therefore, showed another decided increase of cases and deaths. It only goes to show that the menace is still with us; as long as there is hemorrhagic smallpox in the country, intercity and interstate transportation make it easy and certain that unprotected communities will eventually succumb to this devastating disease. Vaccination and revaccination must be constantly urged.

The bitter experience of Colorado, and more especially of Denver, is a perfect object-lesson of what takes place when a lethargic public is not constantly urged and forced to protect itself. The number of cases increased gradually each year, from 268 in 1913 to 2,898 with 7 deaths in 1920; 957 cases in Denver, no deaths. No particular alarm was taken, vaccination was urged, but not carried out with any degree of completeness. In 1921 the situation remained about the same: 2,606 cases and 44 deaths in the whole state, with 924 cases and 37 deaths in Denver. In 1922 there was a decrease in the number of cases, but a terrible type was with us, an extremely virulent type that killed 246 out of the 784 cases. There was a slight lull during the summer months, no deaths in June, and the public was assured that the epidemic was under control; vaccination was still voluntary. With the advent of cold weather the case deaths rapidly increased. One out of every three who had it died; the rest were despaired of for weeks, many suffering from multiple abscesses all over the body, even after the pustules had dried up and the scabs fallen off. The hospital was filled to overflowing with persons that no longer resembled humans, so puffed and distorted, wild with delirium and pain of aching bones and burning flesh were they. The dead were rolled in sheets and laid on the floor to make room for more, most of them past caring what their surroundings were or what became of them.

The disease was no respecter of persons, devastation followed its wake in the homes of the rich as often as in those of the poor. Panic seized the city, and at last thinking people and the physicians of the county medical society woke to the situation, demanding drastic action, publicity, and outside help from the United States Public Health Service in engineering control.

Public gatherings were prohibited; business houses compelled all employees to show a good vaccination scar, and no child was allowed in school without a good recent scar. Free vaccinating stations were opened at convenient locations all over the city-open until 9:00 P.M. for the laboring man—as well as at the

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