Very little effort has been made in the rest of the State until recently to improve the milk supply in the various towns and cities, where the problem is far greater and more difficult of solution. The Public Health Council formulated the sanitary milk code which was put in operation in November, 1914. There has since been a decided improvement in the milk supply of a number of the larger cities, a number now using only pasteurized milk.

The influence of this enlightened attitude with regard to the milk supply can be seen by comparing the number of deaths in 1914 with those of 1915, when there was a decrease of 140 deaths in New York State at large, and an increase of 308 deaths in the City of New York.

The statistics of diarrheal deaths point very conclusively to the fact that these deaths can be prevented by pasteurization and the general improvement of the milk supply. This matter should be brought forcibly to the attention of the public and sentiment aroused to uphold the health officer in his efforts to secure such results.

AN OUTBREAK OF SMALLPOX

How IT WAS CONTROLLED

Sanitary Supervisor Brooks recently reported an outbreak of smallpox in the city of N., county, which involved also the village of

features.

8 miles distant and which presented a number of interesting

Late in August a young man came from Madison, Wisconsin (where later it was learned that smallpox had been prevalent), to visit a brother employed in an industrial plant. It was noted that there were crusts upon his face, but this occasioned little comment among his friends at the time as he was known to be subject to facial eczema. Apparently about 9 or 10 days after his arrival his brother and another young man who boarded in the same house developed an irregular eruption, which it was stated made its appearance first upon the trunk and later upon the face, and also that papules appeared, and in some instances disappeared without going beyond the papular stage, while in the same area others would - become vesicular and disappear, while still others went to a pustular stage.

The patients were seen by physicians who had had considerable experience in the diagnosis of smallpox and, as they and a third boarder in the same house had all suffered some five days previously from some intestinal disorder accompanied by high fever, it was the prevailing opinion that the eruption was that of erythema multiforme of toxic origin.

Before the eruption had disappeared, the two young men, feeling perfectly well, visited the county fair, and the one employed in the industrial plant returned to work.

On September 19 the sanitary supervisor, who had been away, was asked to visit five cases which had just developed at N., and which proved to be cases of mild smallpox. Two of these patients were employes of the industrial plant previously mentioned.

A nurse of experience and judgment was immediately employed to assist in locating and observing contacts, to visit the public schools daily, looking up all children who were absent from school where the cause of absence was not definitely known, and rational publicity was given to the situation through the local daily paper. So far as possible all cases were removed to the local isolation hospital.

About two weeks after the onset of the cases in this group, a teacher in one of the public schools developed the disease. It was then discovered that the janitor of the school building had been having an eruption which had attracted no attention as he was subject to pustular acne. This also proved to be smallpox and he was isolated, the few children remain

ing unvaccinated also being placed under observation, as were all unvaccinated contacts. In this group including the teacher and the janitor of the school there were seven cases, making 15 in all.

Five weeks later, when the outbreak was apparently under control, a man, who had been employed as a farm hand in an adjoining rural town, moved to N., and a few days later it was discovered that he had smallpox in a mild form.

During the time that he was under quarantine, a grocer in the vicinity delivered groceries to him daily. The grocer was one of those who in the past had been opposed to vaccination and neither he nor any of his family were vaccinated. About five weeks after the onset of the above case, a physician called to see a son of the grocer and found that he had smallpox. It then developed that the father had previously been having what was apparently a characteristic eruption and that he had continued the operation of his grocery store. He had called no physician and had kept out of sight of his customers as much as possible. His wife and two children of a near relative, none of whom had been vaccinated, also developed the disease. Fortunately most of those who had come in contact with the above case had previously been vaccinated.

It is worthy of note that among the 21 N. cases none had been successfully vaccinated. On the other hand there were large numbers of contacts, including members of families of patients, who had either been successfully vaccinated within a reasonable length of time, or were vaccinated immediately after exposure, none of whom developed the disease.

One case was unusual and interesting. A man whose wife had the disease in a mild form was not vaccinated until after she had had her eruption for about four days. The vaccination was apparently unsuccessful. Shortly afterward he himself developed the disease in a severe form, and at the time when his eruption made its appearance the vaccination began to "take."

There appears, on investigation of contacts, to have been a direct connection between this outbreak and that at O., where there were some 17 cases. The outbreak at O. was controlled through resort to the same measures that had proved effective in N. Two factors, however, added somewhat to the difficulties encountered: one or two local physicians were very positive in the assertion that no smallpox existed and their opinions were seized upon by those opposed to vaccination as an excuse for avoiding it; nearly 200 persons were vaccinated with a commercial vaccine - very few successfully; this result was afterward attributed to unfavorable transportation conditions under which the shipment of vaccine had been made.

THE PREVENTION OF BLINDNESS

The New York State Commission for the Blind, inaugurating its program and policy for the prevention of blindness, announces the following headings:

Advisory council

A group of ophthalmologists in the City of New York has been invited to act as an Advisory Council with the Commission, to which shall be referred all matters pertaining to the policy of the Commission's work in prevention. Membership on this Advisory Council is as follows:

Dr. Linsly R. Williams, Deputy Commissioner, State Department of Health, Dr. Haven Emerson, Commissioner, City Department of Health, Dr. Wilbur P. Marple, Dr. John E. Weeks, Dr. Alexander Duane, Dr. H. W. Wootton, Dr. Coleman W. Cutler.

It is anticipated that a large group of ophthalmologists and general practitioners will accept affiliation with the Commission for their respective residence districts in the State, in order that cases of eye ailment from such sections reported to the Commission may be referred for prompt diagnosis and treatment.

Nursing service

In December, 1915, the Commission appointed two nurses for follow-up service for eye conditions reported. One nurse has headquarters at Albany and, through the courtesy of the State Department of Health, has desk room and other facilities of the health office available. One nurse has headquarters in the office of the Commission, at 105 West 40th Street, New York City.

Some typical cases referred for such follow-up service are significant of what the Commission hopes to accomplish through extending this service throughout the State:

I Two boys, brothers, with congenital cataracts, whose father refused operative treatment because the boys could "see well enough to hoe potatoes," were referred to the Commission; hospital treatment was secured and the prognosis promises improved vision.

2 A girl of eleven, with acute interstitial keratitis in its second recurrence, and showing a specific history, was referred to the Commission, and by it referred for hospital treatment; under constitutional treatment the vision is improving.

3 A child of eleven, with an injured eye and sympathetic ophthalmia in the good eye, was referred by hospital authorities in order that the parents might be persuaded to allow operative treatment for the injured eye.

4 Two children, brother and sister, with congenital glaucoma and diagnosis of needed enucleation in both eyes, were referred to the Commission and by it referred for hospital treatment where an operation saved both eyes and a very little sight in each case,

5 An adult with cataract for 12 years had never sought treatment, having no funds and no knowledge of clinics or other available service, was found by a Commission's agent and referred for hospital treatment; a successful operation has given good vision in both eyes.

Rural clinics

It is proposed to send a nurse to such rural sections which have no medical service for eye conditions to investigate such conditions and conduct a clinic for their treatment, inviting an ophthalmologist affiliated with the Commission and resident at an adjacent point, to make the diagnosis and prescribe treatment. Two such clinics have been conducted with gratifying results in the cases referred.

The attention of the Commission was called to a history of three cases of ophthalmia neonatorum in the practice of one physician in a period of two years, in which there were disastrous results in each case, and in the most recent case the neglect to treat and failure to report were so obvious that the Commission instituted prosecution under the statute requiring prompt report to the health officer of all cases of ophthalmia

neonatorum.

In the testimony brought out at this trial was the statement that the law requiring such report does not apply to the consultant who sees the case at the request of the attending physician.

A similar question has arisen touching the duty of the nurse to report cases of ophthalmia neonatorum under her care.

The Advisory Council of Ophthalmologists with the Commission, at a recent conference, emphasized the fact that the statute requires both physician and nurse to make prompt report, and that no exemption is allowed in favor of the consultant.

Several cases have come to the attention of the Commission in which had the consultant made prompt report of the condition to the local health officer, a nurse or physician would have been sent and adequate treatment would have been instituted. In each case blindness resulted.

Very effective and compact exhibits on Ophthalmia Neonatorum, Wood Alcohol Poisoning, Midwives, and Trachoma have been prepared by the New York State Committee for the Prevention of Blindness. One on Industrial Accidents to the Eyes will be ready by June 1.

Each subject is covered in five panels, mounted on heavy board and framed, 18 by 38 inches in size, and weighing but a few pounds.

The loan of any or all of these exhibits for use by local boards of health, civic organizations, clubs or individuals interested, may be arranged through addressing the Secretary, New York State Committee. for the Prevention of Blindness, 130 East 22d street, New York City.