exchange of the secretions of the upper air passages. That some of these secretions contain virulent diphtheria organisms is partly a matter of chance and partly a matter of inadequate control. No sane person would contend that every inhabitant of a community should have a culture taken before being permitted to roam at large the labor involved and the resulting inconvenience would be out of all proportion to the results achieved; but the number of virulent diphtheria carriers can be materially reduced and the disease effectively controlled when all sore throats and suspicious contacts are cultured. This means a medical profession willing to take cultures, a public willing to have them taken and abide by the result without prejudice to the physician, and a health department competent to institute proper control and determine within reason what constitutes a "supicious contact." All of these imply a willingness to make an immediate personal sacrifice for an ultimate communal gain and signs are not wanting that it is gradually coming about.

Epidemic cerebrospinal meningitis

In view of the well known tendency of this disease to prevail in military camps, and the possible danger of the dissemination of the disease through carriers brought in as the result of the mobilization of large numbers of troops, the incidence of epidemic meningitis has been observed closely throughout the year. Chart No. 6 shows incidence by months for New York city and for the rest of the State.

The first three months of 1918, figures for which are available. at the time of writing, have been added. During 1917, there were reported from the entire State 483 cases; of these 322 were from New York city and 161 from the rest of the State.

There follows a similar chart (No. 7), presented for comparison, showing incidence by months in New York city and in the rest of the State, for 1916. During 1916, 327 cases were reported in the State, 256 from New York city, and 71 from the rest of the State.

During 1917, the case rate (per 100,000 population) for New York city has been somewhat higher than that for the rest of the State; 5.6 as compared with 3.4 upstate, the general seasonal trend of the incidence curve being the same.

There has been no apparent relation between the local prevalence of the disease and proximity to military camps. Broome county, with 11 cases, had a case rate of 11.5, the highest of the upstate counties. Erie county had the largest number of cases (63) and a case rate of 11. Niagara county followed, with a case rate of 6.1. Steuben, with five cases, had a case rate of 6.

The death rate for the State as a whole showed a very slight increase over 1916.1 (per 100,000 population). On the other hand there was a decrease of .4 or 11.8 per cent over the five-year period 1911-1915. This decrease is no doubt largely due to the more general and early use of antimeningitis serum.

Measles

The case and death rates for measles for the entire State declined slightly from the excessive rates of 1916, the upstate decline being sufficient to overcome an increase in New York city. The upstate case fatality rate was practically the same as for the preceding year; that of New York city fell slightly. The case fatality rate of New York city has always been much higher than the upstate rate, and for the past two years has been higher than its own scarlet fever case fatality rate. A study of the upstate case and death rates, grouped according to the population of the political units, shows only slight differences between the city and rural rates for the year, although there is a progressive decline in the case fatality rates as the sizes of the units diminish. There are two exceptions to this general statement.

The influence of outbreaks in babies' hospitals is the most. powerful one operating on the case fatality and indeed the death rate of communities in which they are located. It is not possible to say without further investigation how many of the thirty-six deaths which occurred in Rochester were institution inmates, but the excessive rate of Albany was due entirely to an outbreak in a maternity hospital and infants' home, which occurred early in the year, 23 of the 32 deaths in the city occurring in this institution. In the same way the case fatality rate and death rate of the group of cities of from 10,000 to 20,000 was made excessive by the occurrence of 52 deaths among 169 cases in a similar institution in Lackawanna.

The case fatality rate for this group,

OF