of the disease are not taken. This ought to be generally known, and many more lives can be saved when all our people come to understand the facts.

In Michigan diphtheria causes about seventeen times as many deaths as smallpox does. I think that it is probably more contagious than smallpox, because the spread of diphtheria is not so easy to trace, and yet we know that diphtheria is contagious, because it is sometimes very easy to prove this, and to trace its mode of spread. Diphtheria seems to be more frequently spread by indirect means than smallpox is; because if it were not, we ought to be able to trace the spread of diphtheria as easily as we do the spread of smallpox. But whether diphtheria is more or less contagious than smallpox, one important reason why we suffer so very much more mortality from diphtheria than from smallpox is the fact that for diphtheria we have no such preventive measure, as vaccination.

Diphtheria is prevented by keeping away from where the disease is, and ⚫ from everybody and everything that has been near the disease; keeping away until everything has been disinfected. In order that this shall be possible, it is essential that every place where diphtheria is shall be promptly reported and plainly placarded. The law requires the local board of health to "give public notice of infected places," and to "use all possible care to prevent the spreading of the infection." Another law requires the health officer to "give public notice of infected places by placard on the premises, and otherwise if necessary." Common humanity requires of every person that he do his utmost to fulfill the letter and spirit of all such laws for the public safety against such a terrible disease as diphtheria.

The law was amended at the last session of the legislature, and its provisions should be generally known. Every householder, hotelkeeper, keeper of a boarding-house, or tenant is required to report to the local health authorities, diphtheria and any other disease dangerous to the public health, and whoever fails to do this is liable to a fine, and to imprisonment if the fine is not paid. Physicians are required to report, and if the physician reports the householder is excused from that duty. Health officers, unless otherwise ordered by the local board of health, must take prompt, thorough and efficient measures to stamp out the disease; and if they neglect their specified duties they are liable to a fine, and to imprisonment if the fine is not paid.

But however good the laws may be, their execution depends upon the enlightened public sentiment of the locality, upon the people themselves, from whom the prompt notice should go to the local health officer, upon intelligent and faithful local officers who should perform duties which are of the highest importance to the people.

SCARLET FEVER.

Scarlet fever is a disease to be dreaded on account of the mortality which it causes, and also on account of the permanent injuries which result from it. Thus, as an instance, of 263 pupils in the Michigan School for the Deaf, at

Flint, during the years 1887-88, who became deaf since their birth, the loss of hearing of 16 per cent. is attributed to scarlet fever.* Of the 114 pupils in the Michigan State School for the Blind, at Lansing, during the two years 1887-88, who became blind since birth, 6.1 per cent. lost their sight from the effects of scarlet fever.†

In Michigan, scarlet fever causes about nine times as many deaths as smallpox does. The only preventive is to keep away from the disease, and to allow no person or article infected with the scarlet fever contagion to come near a person susceptible to that disease.

For its restriction, except that there is no vaccination, all the measures proper in the case of smallpox are proper in scarlet fever.

Inasmuch as scarlet fever causes nine times as many deaths as smallpox does, the importance of prompt notice to the health officer is at least nine times as great as it is in smallpox.

All the other measures should be promptly and thoroughly executed. I will not stop to give you details. They are published in our pamphlets here for distribution.

PRACTICAL RESULTS IN RESTRICTING SCARLET FEVER.

At the close of the year 1887, the statistics published by the State Department showed that the mortality from scarlet fever in Michigan had been reduced in the years when the measures recommended by the State board of health had been, to some extent, fulfilled, so that over 5,600 persons had lived who, under the old mortality rate, before the board began its work, would have prematurely died. This is an average saving of 400 lives per year-rather more than a life every day for fourteen years-saved from that dread disease, scarlet fever.

But we have other evidence than the mortality statistics showing the great saving of life which it is possible to have in Michigan through such measures for the restriction of scarlet fever as I have briefly outlined. The experience of the local health officers in restricting scarlet fever in this State is reported each year to the State Board of Health; and a compilation of these reports shows that in those outbreaks in which isolation and disinfection were neglected there were about five times as many cases and about five times as many deaths as in those outbreaks in which they were enforced.‡

This is about equivalent to saying that four-fifths of the cases and deaths from scarlet fever are known to be preventable through measures which we can describe in three words-isolation and disinfection.

PRACTICAL RESULTS IN RESTRICTING DIPHTHERIA.

While on the subject of the saving of life in Michigan, I may mention that the experience of the health officers in restricting diphtheria in this State is also reported each year to the State Board of Health, and the compilation of

* Eighteenth Biennial Report of the Board of Trustees of the Michigan School for the Deaf.

+ Report of the Superintendent of Public Instruction, Michigan, 1888, pages 78–80.

The evidence for one year, 1888, is shown in the diagram, page 455 of this journal.

these reports shows that 833 lives were saved and 4374 cases of sickness prevented from diphtheria in Michigan during the year 1886, and that in the year 1887 518 lives were saved and 2371 cases of sickness prevented; during 1888 416 lives were saved and 3292 cases prevented.

Thus, during the three years 1886-1888 over ten thousand (10,037) cases were prevented and more than seventeen hundred (1767) lives were saved from diphtheria in Michigan. Or another way of stating this is to say that during the last three years the known saving of life in Michigan from diphtheria has averaged one and a half persons per day.

You may be interested to know the method of estimating the number of cases prevented and lives saved by means of isolation and disinfection. It is as follows: "Multiply the whole number of outbreaks by the average number of cases and deaths in the neglected outbreaks, and the product is the probable number of cases or deaths which would have occurred if all outbreaks had been neglected. Deduct from this number of cases the deaths which actually occurred, and the remainder is the indicated number of cases of sickness prevented or lives saved by the efforts made to restrict the disease.

As the local health officers report to the State Board of Health the number of cases and deaths in outbreaks of diphtheria, and also report just what was done (in each outbreak) to restrict the disease, we are thus supplied with the data necessary to learn the success which attends any line of action which is taken.*

PRACTICAL RESULTS IN RESTRICTING SMALLPOX.

The statistics collected and published by the Secretary of State of Michigan-taken in connection with the facts on record in the office of the State Board of Health-prove that in Michigan, through such measures as I have outlined, the mortality from smallpox has been reduced, and that if it had continued at the same rate as before the State Board of Health was established, more than one thousand five hundred persons in Michigan would have died from smallpox that have not died of that disease. This was true at the end of the year 1887, and since that time the mortality from smallpox in Michigan has not increased. The statistics now cover so many years that we think there can be no doubt of the reliability of their evidence.

The success which has already been achieved in dealing with scarlet fever, diphtheria and smallpox should encourage all to more thoroughly co-operate for the restriction of those diseases, and also to enter vigorously upon the work of restricting typhoid fever and consumption. The relative importance of these diseases can be seen by the diagram which is exhibited here. I believe that one hundred lives per year have been saved from death from smallpox. The diagram is accurately drawn to scale, and correctly represents the relative mortality in Michigan from these important diseases which, we believe, are largely

*The diagram on page 457 of this journal exhibits graphically the experience in restricting diphtheria in Michigan in 1888. + Printed on page 459 of this journal.