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excluding these institutional cases, was .27, and the death rate for the group was 2 per 100,000, as contrasted with 14.8 when the deaths of the institutions are included. The lowest case fatality rate was in the smallest group of villages, where it was only .35, and the death rate per 100,000 was 4.0, practically equal to that of the 5,000 to 10,000 class. It was somewhat surprising to discover that both the death rate and the case fatality rate for the unincorporated towns was about equal to that of the larger cities, the bulk of the mortality occurring in Nassau, Oneida, Onondaga, Rockland and Suffolk counties. Two of the Nassau county deaths were in babies' institutions and all five of the deaths in Rockland county were the result of small outbreaks in such institutions. An investigation of all the deaths showed that 15.6 per cent of them occurred in such institutions. Among the 57 cases which occurred in state institutions (insane hospitals, etc.) there were no deaths. These were of course older patients, and the small number of cases indicates that the disease never became epidemic in any of them. The so-called periodicity of measles outbreaks is not discoverable in the rate for the entire State, perhaps owing to its composite character. The death rate for the State has shown a general decline during the ten-year period covered by the table, the decline being almost entirely due to the decline in the very high rates which formerly prevailed in New York city. The upstate rate has risen and fallen without any regularity in the intervals, though perhaps with as much as has been shown by some authors in their attempt to prove a periodical rise and fall in the death rates of various communities. The decline in the New York city rates seems to be due both to a decrease in the case rate and in the case fatality rate, the latter being probably more influential. It is not known to what extent this is due to keeping the disease out of infant asylums and providing better hygienic surroundings for tenement cases. It is probable, however, that both have had their effect. The high mortality occurring in children's institutions points a way by which the death rate can be materially lowered by seeing that a proper period of quarantine is observed prior to the admission of new patients.

The ages of the decedents indicate the importance of preventing the disease in very young children, as postponement would undoubtedly save many lives. Munson’s study of the outbreak occurring in a military camp in Texas (Military Surgeon, JuneSeptember, 1917) showed that the number of adults who had never had measles was approximately twice as great among residents of small villages and rural districts as among those having lived in larger communities. It is very probable that to some extent at least the lower case fatality rates in the smaller communities are due to attacks at more favorable age periods.

It will be seen from the cumulative graph (Fig. 37) that about 65 per cent of the measles morbidity occurs during the first five months of the year. It has been noted, however, that the earlier the curve begins its ascent in the fall or winter of one year, the higher the curve ascends in the early months of the succeeding year.

Scarlet fever

As will be seen from table 1, page 203, and the graph drawn from it (Fig. 10), the death rate of the State from scarlet fever has declined almost without interruption during the past ten years, although the rate for last year was approximately fifty per cent higher than for the preceding year. This increase occurred both in New York city and upstate, though it was more marked in the latter. The decline in the death rate has occurred despite fluctuations in the case rate, the decline in the case fatality rate being the most influential factor in the reduced death rate. This lower case fatality rate has been most marked during the past three years and has been observed both in New York city and upstate. The figures would indicate that this was not simply the result of better reporting of cases, but is due either to improved treatment or a less virulent type of the disease.

The cumulative graph shown in Chart 11 shows a marked parallelism with the measles curve and shows that approximately 60 per cent of the cases occurred during the first five months of the year. The curve inclines upward in the latter months of the year at a much sharper angle than the measles curve, possibly due to the shorter period of incubation.

*— *= — *=T – — |- –----------& |L rEntire Rest of New York State State City

ANNUAL CASE AND DEATH RATEs PER 100,000 PopULATION FOR SCARLET FEVER, 1908–1917, FoR ENTIRE STATE, NEw York CITY AND REST of STATE

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