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House Document No.492 69th Congress, 2d Session ANNUAL REPORT OF THE SURGEON GENERAL OF THE PUBLIC HEALTH SERVICE OF THE UNITED STATES FOR THE FISCAL YEAR 1926 WASHINGTON GOVERNMENT PRINTING OFFICE 1926 TREASURY DEPARTMENT Document No. 2976 Public Health Service LETTER OF TRANSMITTAL TREASURY DEPARTMENT, OFFICE OF THE SECRETARY, Washington, December 6, 1926. SIR: In accordance with section 9 of the act of Congress approved July 1, 1902, I have the honor to transmit herewith the report of the Surgeon General of the Public Health Service for the fiscal year 1926. Respectfully, A. W. MELLON, Secretary of the Treasury. The SPEAKER OF THE HOUSE OF REPRESENTATIVES. CONTENTS Foreword Division of Scientific Research Cancer Clonorchiasts Goiter Influenza Leprosy investigation station Malaria_ Nutritional diseases Rocky Mountain spotted fever Administrative health practice Child hygiene Industrial hygiene and sanitation Mental health Milk Statistical office Stream pollution Hygienic Laboratory Viruses, serums, toxins, and analogous products Cooperation with State and local boards of health Miscellaneous Division of Domestic (interstate) Quarantine Plague-suppressive measures— Los Angeles Oakland Cities and counties on San Francisco Bay New Orleans Seattle Trachoma eradication Superv.sion of water supplies used by common carriers Interstate sanitary districts Sanitation in national parks Sanitary inspections of shellfish areas Rural sanitation Mosquito control on Texas-Mexican border Advisory comm.ttee on the education of sanitarians Supervis'on of interstate travel of diseased persons Conference of the Surgeon General with State and Territorial health officers Division of Foreign and Insular Quarantine and Immigration: Quarantine transactions General prevalence of quarantinable diseases Changes in quarantine procedure New quarantine station at Mobile, Ala Acquisition of the Texas quarantine system International relations Violation of quarantine laws Summary of transactions at national (continental and insular) quarantine stations Transactions at continental quarantine stations Reports from continental quarantine stations Texas border stations Transactions at insular quarantine stations Reports from insular quarantine stations Transactions at foreign ports Page 1 14 14 16 17 19 23 27 32 33 36 37 42 49 50 51 56 60 69 69 69 70 70 86 87 91 100 101 104 107 122 126 128 129 131 132 132 133 133 134 134 135, 136 136 137 137 138 153 154 154 163 VI CONTENTS Division of Foreign and Insular Quarantine and Immigration—Contd. Reports from foreign ports Summary of quarantine transactions Medical inspection of aliens Examination of prospective immigrants abroad Reports from immigration stations Division of Sanitary Reports and Statistics Morbidity reports Collaborating and assistant collaborating epidemiologists Telegraphic morbidity reports Monthly State reports Annual State morbidity reports City reports Mentally diseased, feeble-minded, and epileptic Foreign reports Prevalence of disease Diseases in foreign countries during 1925 Sanitary legislation and decisions Publications issued by the division Section of public health education Health information by radio List of publications Division of Marine Hospitals and Relief Economies United States Coast Guard United States Employees' Compensation Commission Lighthouse Service Foreign seamen International conference on the health of merchant seamen Clinical work Dental unit Contract physicians Costs of out-patient relief Physical examinations • Radio medical -advice to ships at sea Clinical information Disposition of surplus property Construction and repair • Abstracts of field reports_ Division of Venereal Diseases Cooperative work with ' State health• departments Clinical studies and investigations • Social studies and investigations Publications Educational • work with newspapers and journals Work with the colored population Pamphlets, film showing, lectures, exhibits Rqoorting of venereal diseases Clinics Correctional and penal institutions State laws and regulations: State legislation Court decisions Tabular summary Division of Personnel and Accounts Public-health districts Commissioned medical officers Reserve officers Attending specialists Acting assistant surgeons Internes Contract dental surgeons Epidemiologists Hygienic Laboratory Pharmacists and administrative assistants Boards • Page .164 169 169 170 179 195 195 195 196 197 197 197 197 198 199 201 203 204 204 205 205 209 209 210 213 214 215 215 215 218 218 219 219 222 222 222 224 225 258 258 260 261 262 262 263 263 264 265 267 267 268 268 282 285 289 290 290 290 290 291 291 291 291 291 CONTENTS Division of Personnel and Accounts—Continued. Accounts section Financial statemenL Chief clerk's office: Force on duty in the bureau Printing and binding Public Health Service library Improvements and economies Buildings and office quarters Nursing, dietetic, and reconstruction section Recommendations Appendix • VII Page 292 293 299 299 299 299 300 301 303 305 • ANNUAL REPORT OF THE SURGEON GENERAL OF THE PUBLIC HEALTH SERVICE TREASURY DEPARTMENT, BUREAU OF THE PUBLIC HEALTH SERVICE, Washington, October 15, 1926. July 1, 1902, I have the approved SIR: In'accordance with the act honor to submit, for transmission to Congress, the following report of the operations of the United States Public Health Service for the fiscal year ended June 30, 1926. This is the fifty-fifth annual report of this service, covering the one hundred and twenty-eighth year of its existence. The functions of the Public Health Service as at present organized include (1) the investigation of the diseases of man and the discovery of practical and economical methods for their control; (2) the prevention of the interstate spread of disease and the suppression of epidemics, this latter function being exercised as a rule in cooperation with State and local authorities; (3) the prevention of the introduction of disease and of the immigration of diseased or disabled individuals from foreign countries into the United States; (4) the collection, publication, and distribution of reports of cases and deaths from communicable diseases from ports and places in the United States and from foreign countries with which we have commercial relations, practically from all over the world; (5) the furnishing of medical and hospital relief to merchant seamen (including foreign seamen), to civil employees sick or injured in line of duty, to officers and enlisted men of the Coast Guard Service, patients of the Veterans' Bureau, and to numerous other beneficiaries; (6) the making and recording of physical examinations of applicants for civil service positions, applicants for positions and promotions in the Coast Guard Service, applicants for pensions, and of such examinations for many other purposes • (7) the prevention and control of venereal diseases; (8) the supervision, regulation, and control of the importation and of the sale in interstate commerce of biologic products; (9) public health education and dissemination of health information; and (10) cooperation with international health organizations, with the national health services of foreign countries, with other departments and bureaus of the Government of the United States, with State and local agencies, with volunteer social and civic organizations, and with organized industry in the study and control of contagious and other diseases and in the application of general and specific principles in the prevention of disease and the general improvement of sanitary conditions. 14656-26----2 1 2 PUBLIC HEALTH SERVICE It should be borne in mind that an increase in the facilities for the transportation of human beings and of commodities multiplies opportunities for the introduction of communicable diseases from one State or community into another, and from foreign countries into the United States; that increases in population produce marked tendencies to more than corresponding increases in sickness and death; and that such increases will surely follow unless the means of preventing them are placed at the disposal of our public health agencies, and unless the people themselves will cooperate with their health authorities. Outstanding examples of the results of lowered standards of health administration are perhaps not out of place in this report. I refer (1) to the undue prevalence of smallpox in the United States resulting in quarantine by a foreign government against the State of Florida, and to interstate quarantine directed against persons from the entire United States who were proceeding to the Territories of Hawaii and Alaska, and to the actual suffering and deaths from this disease which occurred in a number of States and cities. All of these inconveniences, and particularly the deaths, could and ought to have been prevented. (2) The undue prevalence of typhoid fever as compared with immediately preceding years. This disease has heretofore been steadily declining since 1900. This decline has not been due to chance, but to intelligent effort; and it is unfortunate that the tendency to a relaxation of effort noted in previous annual reports actually resulted in an increase in the incidence of this disease as forecast. (3) Diphtheria, though steadily declining in recent years, is still far too prevalent. The protection of all children by the administration of toxin-antitoxin would soon result in the extermination of this disease; but if parents will not cooperate in the protection of their children, our health authorities are powerless to give them the benefit of this protection. INVESTIGATION OF DISEASE While the investigative work of the service, directed toward the elucidation of the causes and indicating methods of control of the diseases of man, has been continued under the same major topics as those of last year's report, there has been in every case a progress from one phase of the problem to another. Particular interest attaches to the studies of child health which have followed the same group of children through several consecutive years, making possible an estimate of the effects produced by such factors as underweight, visual, dental, tonsillar, and other physical defects upon the health, progress, and welfare of the children, and also showing the effect, in later years, of the correction of these defects. This unique study is now beginning to bear fruit, as the analysis of various groups of data and their preparation for publication progresses. As a check upon its studies on white children the service has undertaken observations on colored children, who present, on account of their numbers, in portions of the country an important but hitherto unmeasured complication of the health problem. Further studies of narcotic addiction, both clinical and laboratory, have tended only to support the former contentions of this service PUBLIC HEALTH SERVICE that this evil is essentially a part of the larger problem of subnormality, a symptom in fact chiefly exhibited by individuals belonging to that minor but considerable portion of the population which is constitutionally below par mentally and ethically. Under the restrictive measures enforced even imperfectly by law, the evil of addiction appears decidedly to be diminishing, while the more inclusive problem of subnormality still awaits satisfactory solution. The regulation of interstate traffic in biologic products, while a routine and continued activity, has not been without features of public interest. Largely during the past year it has been possible to standardize products used in the prophylaxis and treatment of scarlet fever to an extent warranting their application through commercial manufacture. The earlier results indicate a decided benefit from the use of the antitoxic serum in treatment but a more limited usefulness for the immunizing injections. The experiments in nutritional diseases have made definite progress in further narrowing down the class of substances whose deficiency in the diet is responsible for pellagra, have elucidated a puzzling food factor by showing it to be of Zuble composition, and have paved the way for more rapid and satisfactory experimentation by showing the susceptibility of the white rat to a condition closely simulating if not identical with pellagra. Considerable progress has been made in the studies of the various aspects of industrial hygiene and sanitation. The problem of the dangers to health possibly inherent in the use of tetraethyl lead gasoline has received during the year virtual solution. By an intensive devotion of personnel to various phases of the problem, sufficient dependable data were secured to indicate that, under certain practicable conditions of production, handling, and use, this substance would not present any considerable health hazard. Practical suggestions for these processes have been drawn up, submitted to health organizations as a basis for regulation, and adopted in good faith by the manufacturing and handling interests. The working out of these suggestions is being observed thus far with satisfaction. Several other subjects of interest in industrial hygiene have been studied and a number of publications issued. The menace of the disease known as Rocky Mountain spotted fever has been emphasized during the past year by its apparent spread to areas hitherto unattacked, by an increased case mortality rate in other areas, and by the fact that tourist travel in infected zones is apparently increasing. The control of this disease by direct action either against the ticks which transmit it or the wild animals which are intermediate hosts, seems an almost hopeless proposition on account of the vast and inaccessible breeding places of these species. It is particularly gratifying to report, therefore, the strong hopes entertained by the service of having developed a means of immunizing persons against this disease by prophylactic injections. The initial experiment of the foregoing year was repeated on a much larger scale this season with encouraging results, since there failed to develop a single case of fever in the inoculated groups, although exposure must have occurred, while a number of cases appeared among the uninoculated similarly exposed. If future experience confirms these hopeful results, it may be possible to eradicate the disease by reclaiming the infected areas by an artificially immunized population. 4 'PUBLIC HEALTH SERVICE A new departure on the part of the service in investigating malaria control was signalized by the employment of airplanes for the distribution of arsenical dusts for the destruction of mosquitoes. These experiments give promise of success in adapted areas, and data are being collected as to precise methods and the estimation of costs. The field studies of goiter, a disease distressingly prevalent in some parts of the country, have been continued, with the result of stimulating the interest of health officials, furnishing them with precise methods of survey and making available the best information of the time regarding control. The milk investigations have been vigorously prosecuted, and a widespread interest and renewed activity in the practical sanitation of milk supplies have resulted. One hundred cities have adopted the tentative standard milk ordinance developed by this service as a, result of these studies, and at the annual conference of State and Territorial health officers with the Surgeon General this ordinance was indorsed for adoption by all the States represented as embodying a uniform procedure to be recommended to communities. In actual operation this ordinance has been observed to be adopted with little opposition, to be capable of'enforcement, and to result in measurable improvement in the sanitary quality and at the same time in increased consumption of milk. These studies have now been extended to the investigation of the mechanical features of proper pasteurization. Studies in stream pollution, in addition to increasing our knowledge of natural and artificial purification, have succeeded during the year in laying the basis for impartial settlement of an interstate situation before it assumed the nature of controversy, and another similar investigation is now in progress. PREVENTION OF THE INTERSTATE SPREAD OF DISEASE: RURAL SANITATION Campaigns for the eradication of bubonic plague in rodents were successfully completed at New Orleans, La., and at Oakland, Calif., as was the campaign against human and rodent plague at Los Angeles, Calif. Measures for the routine trapping and examination of rodents are either in force or in process of organization in these cities as permanent- activities of the local health departments and should furnish a reliable index both as to the degree of infestation and as to the character of any infection that might be found among the rats. The only plague which now exists on the North American Continent is that among the ground squirrels of California. This infestation is widespread and may be expected to give rise to outbreaks of human and rodent plague from time to time in the cities and towns in this territory unless far more extensive operations than those hitherto in force are undertaken. The cooperative rural health work continues to be one of our most important and productive activities. The fact that 84 per cent of our rural population is as yet unprovided with adequate official local health service—the lack of which causes loss of human life and earnings estimated at approximately $1,000,000,000 each year—is sufficient evidence of the need of participation of the Public Health Service in the development of local health work. PUBLIC HEALTH SERVICE 5 Measures for safeguarding shellfish from pollution and contamination as conducted in cooperation with the Bureau of Chemistry and the Bureau of Fisheries, have resulted in great improvements in the methods used by the producing States, and in renewed confidence in the safety of shellfish on the part of the consuming States. Reasonably uniform rules, regulations, and methods of enforcement are being developed which will result in better observance as well as in better enforcement. It is gratifying to note that measures for insuring safe drinking water supplies on interstate carriers, both trains and vessels, are meeting with better results each year, due to the increasing appreciation of the value of this work on the part of the companies concerned. The railroads have now practically completed the installation of the new type of water coolers for passenger cars wherein there is complete separation of the ice and drinking water. Assistance has been rendered the National Park Service in the designing and installation of sanitary equipment in the national parks and in maintaining proper sanitary condition§ in the numerous camps, hotels, dining rooms, and kitchens. The vast and increasing number of sight-seers and tourists who come to the national parks from every part of the United States and journey thence to many other parts makes sanitation imperative as a measure for the prevention of the interstate spread of disease. FOREIGN QUARANTINE AND IMMIGRATION There has been no importation of plague, cholera, yellow fever, or other major quarantiliable disease during the year. This freedom from such importation has been accomplished with a minimum delay and expense to shipping and the traveling public, although the health conditions throughout the world show a slightly more threatening condition than at the time of my previous report. In this connection it should be noted that the reported incidence of cholera increased considerably. There have been no marked diminutions nor recessions in the plague situation throughout the world, although it is believed that this disease has been eradicated from New Orleans, La., and Oakland, Calif. Smallpox is present, to a less extent, practically everywhere, the disease having had a wide prevalence in the United States, especially in Florida and California. Typhus fever, which has in previous years rapidly receded, stimulated, no doubt, by the strict bodily cleanliness required for those entering the United States, has during the past year practically remained stationary. Recognizing that the prevention of the importation of epidemic diseases is based upon epidemiology, which must be constantly advancing, action has been taken to improve quarantine methods, making them more efficient, more precise, and ,less burdensome to commerce. Changes in quarantine methods were recognized in the international conference held in Paris, in which the Public Health Service took an active part, resulting in the adoption of a treaty which will insure more scientific and efficient treatment of quarantine problems. An amendment to the quarantine regulations which will allow, in 6 PUBLIC HEALTH SERVICE certain instances, fumigation to be based upon actual conditions of the vessel and less upon routine procedure was authorized. Certain decisions were made, notably regarding the disinfection of rags, that testify to the rapid advance of maritime quarantine as a scientific procedure. The inspection at European ports of emigrants intending to come to the United States, which was begun during the year, is apparently an unqualified success. It has, however, been a severe drain upon the medical personnel of the service, both on account of the number of officers needed and the special training required. The advantages and disadvantages of making examinations of emigrants previous to their definitely leaving their homes have been discussed for years. It is therefore believed that the report, given later, covering this work will be of considerable interest. MORBIDITY REPORTS: PREVALENCE OF DISEASE Changes are taking place which render the work of health officers more difficult and at the same time more important than it was a few years ago. The tendency to concentrate in the larger centers of population facilitates the spread of diseases dangerous to the public health, and makes necessary rigid supervision over water and milk supplies and the disposal of wastes. Improvement in the means of transportation by sea, land, and air have had the effect of bringing- closer together communities which have been considered as widely separated. In our own country hundreds of thousands of persons travel by automobile from State to State, especially during the vacation time. This and other modes of intercommunication make the presence of communicable diseases in any State of interest to every other State. An earthquake in Japan arouses our sympathy, but it does not endanger our safety but smallpox in England, cholera in Siam, plague in Egypt, or trachoma in Russia may be conveyed to our shores and introduced among our people in a very short time. A widespread epidemic of diphtheria in Canada will probably cause cases of this disease in the United States. In spite of all practicable precautions, typhus fever cases from Mexico are occasionally found in the Southwest. The responsibilities of health officers—Federal, State, and local— are increasing, but our knowledge of disease is also increasing. We now know the methods by which many of the more important communicable diseases are transmitted, and this knowledge enables the health officer to take action to prevent the introduction or spread of these diseases. Some diseases—smallpox and diphtheria, for instance—could be practically eliminated if the public could be made to realize the advantages of using well known methods of prevention. Thousands of persons in the United States suffer and die each year because of lack of available information or indifference which prevents the use of methods of prevention, the efficacy and safety of which have been proved. Even when the results are reckoned only in dollars, intelligent, properly directed health work pays large dividends to the community. PUBLIC HEALTH SERVICE 7 Comparable statistics of deaths in the United States are available since 1900, when regular publication of returns from the registration area was begun by the Bureau of the Census. The death rate in the registration area decreased from 17.5 per 1,000 population in 1900 to 11.6 in 1921, which was the lowest year for which complete returns have been received. In 1918, the year of the influenza epidemic, it rose to 18.1 per 1,000, but in general the decrease has been gradual and fairly steady. In 1922, the rate was 11.8 per 1,000; in 1923 it was 12.3; and in 1924, 11.9. Incomplete returns show very little difference in the general death rates for the years 1924 and 1925. In the combined populations of 30 States the death rate was 11.7 per 1,000 population in 1925. Thirty States reported 1,727,467 births for the calendar year 1925. This gives a birth rate of 21.2 per 1,000 population, which is 6.2 per cent lower than the birth rate in these States for the year 1924 (22.6 per 1,000). The figures for the birth-registration area since 1915 show a considerable decline in the birth rate, which dropped from 25.1 per 1,000 population in 1915 to 22.4 in 1923. Since 1915, when comparable figures covering a considerable area were first made available, there has been a decided decrease in infant mortality in the United States. In 1915 there were 100 deaths of infants under 1 year of age for each 1,000 births. The rate rose to 101 per 1,000 births in 1916 and again in 1918; then it gradually decreased to 75.6 in 1921. In 1922, the rate was 76.2 per 1,000 births; and in 1923 it was 77.2 per 1,000. These figures are for the birthregistration area, which included 31.1 per cent of the population of the United States in 1915 and 72.2 per cent in 1923. Reports for 30 States give a rate of 71 deaths under 1 year of age per 1,000 births in 1924 and 71.5 in 1925. These figures are low as compared with the infant mortality rates of most foreign countries. New Zealand has the best record in this respect, the infant mortality for the year 1923 being 43.8 deaths of infants under 1 year of age per 1,000 births. In England and Wales the rate was 69.3, and in Scotland, 78.9. In Canada, in 1922, the rate was 86.8. Holland in 1922 had 'an infant mortality rate of 67.3. In Germany, in 1921, the rate was 133.8; in Japan, in 1921, it was 168.3; in Ceylon, in 1923, it was 212. During the calendar year 1925 smallpox of a virulent type was present in a number of cities in the United States. In most of these communities the disease had been present in mild form for years, there being some cases each year, with occasional epidemics, but very few deaths. Usually during the excitement incident to the epidemics, persons who were known to have been exposed to the disease and some others were protected against the disease by vaccination by health officers or their family physicians. In some cities laws or regulations requiring vaccination before attending school were enforced for a time, but the excitement soon abated after the disease was checked, and vaccination was neglected until the next epidemic. The typhoid fever death rate in the registration area in 1900 was 35.9 per 100,000 population. The rate declined steadily, and in 1924 it was 6.7 per 100,000. In 1925 there was a reaction. Thirty- 8 PUBLIC HEALTH SERVICE five States reported 5,352 deaths from typhoid fever in 1924, and 7,430 deaths in 1925. It is perhaps significant that nearly all of the increase occurred in rural districts and smaller cities. The cities having 100,000 population or over had nearly the same aggregate rate in 1925 as in 1924. During the last quarter of a century the death rate from typhoid fever in the death registration area of the United States has been reduced more than 80 per cent; the death rate from tuberculosis about 55 per cent; and the rate from diphtheria 70 per cent. These are some of the records which sanitarians contemplate with pride, and from which they receive courage for future work. Other communicable diseases show creditable reductions in both case and death rates, but the official records for some diseases are not so encouraging. The death rates from cancer, diseases of the heart, diabetes, and other diseases are increasing, while automobile accidents, unknown a few years ago, are taking a toll of human life which is appalling. The steady increase in deaths and disablements from this cause each year is disheartening to the person who sees the suffering and loss of life as well as the saving of time in transportation and the greater freedom of movement which the automobile has brought to our people. MEDICAL AND HOSPITAL RELIEF Hospital care and other medical services have been provided in different ports in the United States, Alaska, and the insular possessions for the treatment of merchant seamen and other beneficiaries of the service. A total of 1,321,309 hospital patient days, 572,139 out-patient treatments, and 91,553 physical examinations were furnished. The number of lepers segregated at the National Leper Home has increased to 259. The Marine Hospital on Ellis Island has continued to admit all sick and detained immigrants whose treatment was requested by the Department of Labor, including an increasing number of alien seamen with venereal and other contagious diseases. The number of merchant seamen and other regular beneficiaries of the service admitted to this hospital now outnumber detained aliens. CONTROL OF VENEREAL DISEASE The program of venereal disease control which has been built up in the eight years since the creation of the Division of Venereal Diseases has been found, on the whole, satisfactory. The development of the work of this division has followed mainly the duty of cooperating with State boards of health for the prevention and control of venereal diseases within the States and for the study and investigation of conditions influencing the spread of the diseases. Throughout the country there has been built up a unified method of prevention and control of these diseases; more than 900 clinics have been established where scientific treatment is provided to indigent patients without cost or for a nominal fee; educational pamphlets, motion-picture films, stereopticon slides, and exhibits have been made available through each of the State boards of health; standard laws and ordinances have been enacted throughout the country, tending to unify the program of control. A review of the field to be covered PUBLIC HEALTH SERVICE 9 and the work that has been done indicates an outstanding achievement in modern public health effort. COOPERATION WITH OTHER AGENCIES The Public Health Service cooperates extensively with other agencies—international, Federal, State and local, with volunteer social organizations, and with industrial institutions. Among these cooperative activities may be mentioned the following: (1) Cooperation with the International Sanitary Office of Paris in attendance at conferences and at meetings of the personnel constituting this office. (2) With the Health Section of the League of Nations in collecting, publishing, and distributing information of the prevalence of disease. (3) With the Department of State in examining emigrants abroad and with consular officers in the administration of quarantine. (4) With other bureaus of the Treasury Department in rendering all medical services for the United States Coast Guard, including examinations for enlistment and retirement and the detailing of medical and dental officers to cutters and bases; issuance of certificates for possession and purchase of medicinal liquors for the Prohibition Unit, Bureau of Internal Revenue; issuance of authority for purchase of narcotics for medicinal use aboard ship for the Narcotic Division, Bureau of Internal Revenue; assistance given the Prohibition Unit in investigations of the relative toxicity of "bootleg"and commercial liquors; advice and suggestions upon chemicals for inclusion in the schedule of supplies to the General Supply Committee. (5) With the Departments of War and Navy in rendering medical treatment for designated 'personnel of the Army Engineer Corps and Mississippi River Commission; medical relief 'upon official- request for personnel of the Army, Navy, and Marine Corps; in cooperative studies with the Marine Corps of the efficiency of Paris green as an A nopheles larvacide when spread from an airplane; and lectures by the hygienic laboratory staff members to naval medical student officers. (6) With the Department of Justice in suppressing fraud. k 7) With the Post Office Department in the supervision of firstaid stations in certain post offices; tests to determine the most efficient system of lighting in post offices; and in the prosecution and prevention of fraud. (8) With the Department of the Interior in the examination of applicants for the Bureau of Pensions; reorganization of the medical service for the Bureau of Indian Affairs; for the National Park Service in the examination and treatment of a large number of indigent persons afflicted with venereal diseases visiting Hot Springs; in assistance given the National Park Service in designing. and installing water-supply systems, sewage-disposal systems, incinerators for the disposal of waste and the like, and in maintaining general sanitary conditions in the national parks. (9) With the Department of Agriculture in furnishing laboratory facilities and assistance in experimental work and publications; 10 PUBLIC HEALTH SERVICE detail of a sanitary engineer of the Public Health Service, at the request of the chief of the Forest Service, to make a sanitary survey of various parks under the supervision of that service, and to recommend sanitary measures in enforcement of plant and animal quarantines; the work of cooperating with the Bureau of Chemistry in the sanitary control of shellfish, in accordance with the terms of the interstate quarantine appropriation for that purpose; and in conferences held with the Bureau of Animal Industry relative to international standards for tuberculin. (10) With the Department of Commerce in rendering medical treatment for designated personnel of the Lighthouse Establishment, lighthouse vessels, Coast and Geodetic Survey, and Bureau of Fisheries; cooperation continued with the Bureau of Standards in study of occupational hazards among employees, and with the Bureau of Mines in the detail of a regular medical officer of the Public Health Service to that bureau; study in cooperation with the Bureau of Fisheries of fish control of mosquito breeding; attendance at conferences upon the standardization of thermometers and of disinfection technique of members of the staff of the Hygienic Laboratory. (11) With the Department of Labor in the examination of immigrants and treatment and detention in hospital of diseased aliens; examination of emigrants abroad. (12) With the Civil Service Commission in the examination of applicants for appointment and retirement; preparing questions for examinations and rating of papers in several examinations held by the commission. (13) With the United States Shipping Board in the instruction in first aid and examination of vision and color vision of pilots and other ship's officers for the Shipping Board and other owners. (14) With the United States Employees' Compensation Commission in the examination and treatment of disabled Federal employees, and in special investigations. (15) With the United States Veterans' Bureau in the examination and treatment of patients; inspection of well and water supply at Edward Hines, Jr., Hospital, Maywood, Ill.; advice upon the organization and equipment of a scientific research division; the performance of 494 Wassermann tests for hospitals in various parts of the country. (16) With State and local health and other agencies. Cooperation with States in the control of venereal diseases; cooperation with State authorities in water certification procedure, which work has been conducted in cooperation with the division of sanitary engineering of 29 States; cooperation with the 19 shellfish producing States in the sanitary control of the shellfish industry; cooperative studies of, and demonstration work in, rural sanitation carried out in 89 counties of 20 States, as follows: Alabama Arkansas CalifOrnia Georgia Illinois Iowa Kansas Kentucky Louisiana Massachusetts 9 2 3 8 1 1 4 1 2 1 Mississippi Missouri Montana New Mexico North Carolina Oklahoma South Carolina Tennessee Virginia West Virginia 3 13 2 8 1 3 1 6 12 8 PUBLIC HEALTH SERVICE 11 a part of the This demonstration work in rural sanitation is madehealth service. y count -time whole ounded well-r of am progr ,general health deIt results in the development of efficient whole-time rural ped. develo be not would ation, cooper such ut witho , which partments, indusof office the of part the on n Eastern States. Cooperatio State departtrial hygiene and sanitation investigations with the tions for the regula of tion forma ment of labor and industry in the the municipal control of spray painting in Pennsylvania; study of n Ohio River certai with ation water-purification plants in cooper the natural cities; study of the vision of school children and of bia; study Colum of ct Distri the illumination of school buildings in state-wide of the growth of school children of Hagerstown, 3,1d., husetts; Massac and ticut Connec _goiter surveys of Khool children of District of survey of school children of Cincinnati, Ohio, and the enlarged for en childr school of Columbia; and the examination a. malari of ce spleen as eviden Health of Southern States.—Cooperation with the State Board of epidemiof on divisi the of on nizati reorga the in na North Caroli of States the with ation cooper in l ()logy ; studies of milk contro CaroSouth see, ia, Tennes Virgin , Texas na, Caroli North Alabama, cooperation lina, Missouri, Kentucky, Arkansas, and Louisiana; determining in na Caroli South of h Healt of Board with the State zing a divithe prevalence of anterior poliomyelitis, and in organi ; coophealth of board State the of ering engine ry •-sion of sanita tion preven in a Florid in ities eration with the State and local author ana Louisi of State the with ation cooper pox; small of the spread of s studie res; measu ative eradic e and the city of New Orleans in plagu ia, Virgin sippi, Missis of States the with ation cooper of malaria in in other Georgia, and Alabama, also surveys made and advice given mental and al physic the of study em; probl a is a States where malari iauthor health State the Ga.; status of colored children in Atlanta, VirWest and ia, na, Virgin Caroli North cky, Kentu ties of Georgia, service officer ginia asked and received' assistance by the detail of a ation with cooper ions; infect wn unkno or e remot of in the diagnosis the Texass along nitie commu the Texas State Board of Health and ility of possib the t preven to ation eradic ito mosqu Mexican border in •the spread of yellow fever. local auMiddle Western States.—Cooperation with State and clinics field and als hospit thorities in the maintenance of trachoma ed at operat being als hospit these oma, trach of for the eradication lle, Tenn.; Rolla, Mo., Russellville, Ark., Eveleth, Minn., and Knoxvi ty of the qtudy of the sewage pollution of Lake Michigan in the vicini MisIndiana-Illinois State line, and of the pollution of the upper sota Minne and nsin Wisco the with ation sissippi River in cooper of St. Paul and State health departments and the health authorities Minneapolis. sco and Western States.—Cooperation with the city of San Franci plague in Bay sco Franci San of ty vicini the the cities and counties in n of plague in .eradicative work, consisting of (1) the exterminatiorodent surveys (2) es, measur l contro t ground squirrels and roden operation of a and sanitary inspections in San Francisco, an (3) the city of with ation cooper es; purpos laboratory for diagnostic undertaken was Los Angeles in plague eradicative measures, which 12 PUBLIC HEALTH SERVICE at the request of the city authorities and consisted in aiding thecity in the elimination of rodent plague; minor cooperative assistance given the States of California and Oregon by the office of Stream Pollution Investigation; study of the dental condition of children in a county in New Mexico. Hawaii.—Cooperation with the Territorial Board of Health in leprosy investigations. With universities, organized social agencies, etc.: Cooperation at various times regarding technical matters with the American Public Health Association, the International Institute of Statistics, Milbank Memorial Fund, National Safety Council, Girl Scouts of the District of Columbia; cooperation with sick benefit associations and medical departments of industrial establishments in studies of the causes of industrial absenteeism; laboratory facilities and other valuable assistance furnished to the Division of Scientific .Research in connection with investigations of cancer, pneumonia, municipal health practice, and leprosy by the universities of Harvard, Cornell, Johns Hopkins and Hawaii; cooperation with the Annual Tuskegee Negro Conference and the National Negro Business League in the National Negro Health Week program;. conferences with the research committee of the National Tuberculosis Association on plans for new work; investigation of suspected cases of leprosy; in accordance with arrangements, facilities for study and instruction were granted seven representatives of foreign governments holding fellowships under the International Health Board, three being from Hungary and one each from Norway, Italy, Yugoslavia, and Bulgaria, the time spent at the Hygienic Laboratory varying from a week to about three months in individual cases. Reagents, test sera, or cultures were sent to the following: HOSPITALS Stanford Hospital, San Francisco, Calif. Theda Clark Hospital, Neenah, Wis. John McCormick Institute for Infectious Diseases, Chicago, Ill. Wesley Memorial Hospital, Emory University, Ga. St. Elizabeth's Hospital, Hannibal, Mo. Jackson Infirmary, Jackson, Miss. South Mississippi Charity Hospital, Laurel, Miss. Johns Hopkins Hospital, Baltimore, Md. Jefferson Hospital, Philadelphia, Pa. Hebrew Hospital, Baltimore, Md. Meriwether Hospital, Asheville, N. C. Children's Hospital, Washington, D. C. Latter Day Saints' Hospital, Idaho Falls, Idaho. Mercy Hospital, Pittsburgh, Pa. St. Luke's Hospital, New Bedford, Mass. Georgia State Sanitarium, Milledgeville, Ga. Methodist Episcopal Hospital, Indianapolis, Ind. New Haven Hospital, New Haven, Conn. EDUCATIONAL INSTITUTIONS Boston University School of Medicine, Boston, Mass. University of Rochester, Medical School, Rochester, N. Y. University of California, Berkeley, Calif. Medical College of Virginia, Richmond, Va. College of Medicine, University of Cincinnati, Cincinnati, Ohio. Yale University, department of medicine, New Haven, Conn. • PUBLIC HEALTH SERVICE 13 Thilver§ity of Kansas, Lawrence, Kans. 'Harvard University, medical department, Boston, Mass. Vanderbilt University, medical department, Nashville, Tenn. Chicago, Ill. ;University of Chicago, department of hygiene and bacteriology, Iowa. City, Iowa Iowa, of ty Universi State Cornell University, veterinary department, Ithaca, N. Y. N. Y. Columbia University, department of bacteriology, New York, Johns Hopkins University, Baltimore, Md. Michigan State College,.Lansing, Mich. Lehigh University, Bethlehem, Pa. University of Florida, Gainesville, Fla. Wake Forrest Medical School, Wake Forrest, N. C. Baylor University, Waco, Tex. Rockefeller Institute for Medical Research, New York, N. Y. , San Francisco, The George William Hooper Foundation for Medical Research ,Calif. PERSONNEL Attention is again invited to the necessity of increasing the regular commissioned corps of the service. During the past year Congress recognized this need by appropriating for 10 additional assistant surgeons, intended as a replacement for officers detailed to the work of examining intending immigrants in Great Britain and the Irish Free State. This work has now been extended to other European ports, its desirability and value having been demonstrated to the satisfaction of the State Department, the Immigration Bureau, and Public Health Service officials. At the present time 28 commissioned officers have been sent to various European ports for the medical examination of immigrants. This number, added to .officers on duty in connection with quarantine measures at foreign ports and in insular possessions, totals more than 25 per cent of the .commissioned corps on active duty. Authority for additional officers in the regular corps would enable the service not only to train officers to replace those who have comon in pleted a tour of duty abroad, but would also permit of a reductiduty. on now officers reserve and ees the number of local appoint The compensation of certain local medical appointees at important immigration and quarantine stations is not commensurate with their responsibilities. On this account resignations have occurred which be adversely affected the work. The pay of these officers can notThe . iations appropr the of acy inadequ the of account on ed increas .appropriations for this purpose should be increased. SCIENTIFIC RESEARCH DIVISION In charge of Asst. Surg. Gen. A. M. STIMSON The objectives, principles, and general methods regarding the. operations of this division have been recorded in previous annual reports. It will be noticed that the general topics of investigation have remained substantially the same. The reason for this resides in the inclusive nature Of these designations rather than in a lack of progress. While it can be foreseen, perhaps, that the time is not far distant when such a disease as malaria may cease to be of major importance in the United States, and consequently no longer in need of intensive study leading to its control, the possibilities of dismissing such a subject as stream pollution within a short period of years would appear more remote. This is due to the appearance of new problems incident to the rapid growth of populations and of industry—problems which for some time will require very serious study if catastrophe is to be avoided. Thus it has happened in many of these research activities that the solution of one problem has scarcely been consummated before a change in the social or economic situation of the population presents another for investigation. While this may be regretted by those who desire and hope for an early millenium, a sober recognition of fact will lead to the conviction that, unless the human race should stand still, it will continue to offer health problems for solution. The fact that health knowledge actually has kept pace with other advances sufficiently well to result in a diminishing death rate and prolonged life in spite of increasing congestion and what may be designated as an accelerated rate of living should be sufficient guaranty of the essential soundness of scientific methods applied to the solution of health problems. CANCER Investigations of cancer were continued during the fiscal year under the direction of Surg. J. W. Schereschewsky, with headquarters furnished by the Harvard Medical School, Boston, Mass. In the search for therapeutic agents which might favorably affect the course of malignant growths or be useful in their prevention an almost infinite variety of drugs, serums, and physical agents has. been investigated by the medical and allied professions. Effects upon living cells of currents of very high frequency.— While considerable work has been done in the past on the effects on, living cells of high-frequency currents generated by the usual form of therapeutic apparatus, the effect of continuous wave oscillations,' of very high frequency upon living cells has been, if at all,, little investigated. 14 PUBLIC HEALTH SERVICE 15 Progress in the construction of vacuum tubes and development of the associated circuits have permitted the generation of oscillating currents of very high frequency. Since the number of bands in the spectrum of radiation are concerned in biologic phenomena, it was thought that this h'therto unexplored region might well repay investigation. Consequently, the study which was commenced in the last half of the previous year was continued throughout the present year. The first step in this study was the development of oscillating circuits capable of generating oscillating currents of the frequency it was desired to study (230,000,000 to 10,000,000 cycles per second) and of associated apparatus in which laboratory animals or living cells could be suitably exposed. The development of these circuits was carried out at the Cruft high-tension physical laboratory, Harvard University, the facilities of which were very kindly placed at the disposal of this office by the &rector and assistant director of the laboratory, Profs. George W. Pierce and E. L. Chaffee. This cooperation was of much assistance and is gratefully acknowledged. Suitable apparatus having been developed for the investigation, the first step of the study was to determine whether change in frequency produced any difference in the effects observed. When living cells were exposed to the displacement current in an electrostatic field profound effects were produced which resulted in the death of the organism. These effects were most marked in a particular band of frequencies extending from a frequency of about 90,000,000 to 10,000,000 cycles per second, the effects on the one hand diminishing with great rapidity for lower frequencies and more slowly for higher frequencies. The detailed results of this part of the study are now in press. Further studies are being at present carried out on the effect of these currents upon the growth of malignant tumor cells, their effects on seed germination, their effects on the growth and development of young animals, and histological studies are being conducted of the morbid changes produced in tissue cells. Investigation of the racial mortality from cancer in the United States.—Since European statistics show great racial dissimilarity in various death rates from cancer (which, however, may,in some part, be due to differences other than racial, as, for example, differences in the methods and accuracy of reporting deaths, differences in medical facilities, and the extent to which they are utilized by different nationalities, and similar factors) an attempt was made to study the racial mortality from cancer in the United States in some particular section where, presumably,the environment would be substantially the same for all races. An intensive study of the metropolitan area in Boston was undertaken particularly with respect to the extent to s for which the various races present avail themselves of the facilitiecause well might respect this in ces medical treatment. Differen variations in the recorded death rate of the different races. For instance, if one race were shown to avail itself more readily of medical would treatment than another, diagnosis would be earlier, treatment course the have would age percent higher be earlier initiated, an a cancer of the disease arrested. All the certificates of deaths from over gone were years ng precedi three the which had occurred within from the records of the city department of health, and personal visits 16 PUBLIC HEALTH. SERVICE were made by the field workers to the homes and relatives of the deceased for the purpose of securing the necessary information in regard to medical treatment. This part of the investigation was attended with considerable difficulty because of the fact that, in many instances, relatives could not be found. The data on file at the large hospitals in Boston such as the Massachusetts General Hospital, Boston City Hospital, and the Long Island Hospital were studied, as well as those of the Community Health Association. Seven hundred and eighty complete schedules were secured. stumblingblock to the early completion of this study is the fact that up to the present date it has been impossible to secure a distribution of the population according to age and race. Consequently, it has not been possible to verify the apparent result of this study, i. e., that the Italians possess the lowest mortality from cancer of any of the races of Boston, as the apparent low rate in Italians may possibly be due to a different age distribution. It would not appear, so far as Boston is concerned, that there can be any ground for belief that differences in the availability of medical treatment can cause an apparent difference in racial mortality, as all the races appear to be on an equal footing in this respect. The study will be completed as soon as it is possible to secure an age distribution of the population by race. CLONORCHIASIS Investigations of clonorchiasis are being continued at San Francisco, Calif., under the direction of Surg. N. E. Wayson. The object of the study is to determine whether the liver fluke, Clonorehis 8inensis, may become prevalent among the lower animals and in man on the Pacific slope. In accordance with the accepted hypothesis of the life cycle of the parasite, its reproduction in snail and fish hosts under laboratory conditions has been the immediate objective during the past year. The method of approach to the problem has been through attempts to maintain in aquaria those conditions which might favor the development of the parasite in the intermediate hosts and through more extended studies of the factors which might favor or produce the hatching of the egg of the parasite. These latter efforts have been somewhat curtailed during the latter months of the year because of the small number of infected aliens submitted for examination to the chief medical officer of the San Francisco Immigration Station, through whom fresh specimens of ova-containing materials have repeatedly been obtained. However, previous observations of varying single and combined physical, chemical, and mechanical factors on washed preparations involving many thousand eggs have been extended. The factors included have been the time period, the temperature, light, exposure, and reaction of the suspending medium, the degree of mrobiosis, and the effect sof interference with both chemical reagents and mechanical agents. Prolonged exposures for several weeks or months under these varying conditions, as well as abrupt changes, have been studied. Constant findings which will permit of conclusions as to the manner or possibility of spread on the Pacific slope have not been determined from the experiments made. It has been observed that PUBLIC HEALTH SERVICE 17 both physical and chemical combinations will effect the dehiscence of the egg and the emergence of the contained larval form. Also that eggs which are ingested by snails become dehiscent during their passage through the intestinal tract of the snail. However, consistent spontaneous hatching of these larval forms in an active condition has not been obtained. During these studies the snails suspected of being the intermediate hosts of the parasite in the areas of both China and Japan in which the disease is endemic have been imported in the dry state, have been kept alive for eight months, and have reproduced in aquaria under laboratory conditions. The feasibility of such importation and adaptation to aquarial conditions may be of significance in the local development of both the snail and the parasite under natural conditions. Other Japanese snails have been imported, through commerce, for aquarial purposes, and in order to establish a local supply, or through carelessness, these have been planted in the local fresh waters of the Pacific slope and have become indigenous. However, the life cycle of the parasite has not been developed in the imported or local snails and fishes which have been maintained in laboratory aquaria during this 'investigation. GOITER Goiter studies were continued during the year under the direction of Surg. Robert Olesen. The year was devoted largely to the compilation, study, and presentation of data relating to the effects of endemic goiter as it prevails in Cincinnati. As a result of these studies several interesting contributions have been made to the present-day knowledge of the subject. Endemic goiter in Connecticut.—A survey was undertaken in Connecticut for the purpose of determining the extent and distribution of endemic thyroid enlargement. Surveys made in 28 representative communities included 5,797 boys and 6,608 girls attending high schools and the higher grades of grammar schools. Seven per cent of the boys and 29.4 per cent of the girls examined had thyroid enlargements, but mostly of very slight degree. Owing to the relatively slight incidence of goiter in Connecticut, wholesale prophylaxis is deemed unnecessary. In certain localities, however, preventive measures among adolescent girls have been recommended. Endemic goiter in Massachasetts.—Preliminary thyroid surveys in Massachusetts made by members of the State department of health apparently disclosed foci of goiter endemicity, particularly in the western portion of the State. Subsequently a more intensive survey was made by the Public Health Service, 57 representative localities being visited. In all, 7,140 boys and 10,057 girls were examined for evidence of thyroid enlargement. The percentages of thyroid enlargement, 8.7 per cent among the boys, and 22 per cent among the girls, approximate very closely, as might be expected, the Connecticut figures. At the close of the year the data accumulated during the Massachusetts survey were in the process of compilation and study. Endemic goiter and intelligence.—In an effort to determine the influence of endemic thyroid enlargement upon intelligence, 1,902 18 PUBLIC HEALTH SERVICE boys and 1,894 girls in the sixth grade of the Cincinnati schools were studied. A'nalysis of chronological age data indicative of school retardation or advancement failed to reveal significant variations between thyroid-normal and thyroid-enlarged children. Furthermore, a comparison of percentile ranks, obtained by the application of intelligence tests, failed to show differences of sufficient magnitude to warrant the conclusion that the thyroid normal have a keener mentality than the thyroid enlarged.' It is to be understood that these findings and others based on individual surveys may p,rove to apply only to the particular conditions locally encountered, and no attempt is made to generalize from them. Goiter and potential foci of infection.—It is frequently stated in the literature that goiter is due to foci of infection, such, for instance, as reside in decayed teeth and diseased tonsils. In order to gain some information upon this point, a study was made of the thyroids, teeth, and tonsils of 1,341 white boys and 1,576 white girls in Cincinnati. Some degree of thyroid enlargement was present among 38.4 per cent of the boys and 58.8 per cent of the girls. A careful study of the material gathered during this investigation failed to disclose a definite relationship between thyroid status and potential foci of infection presumably located in decayed teeth and enlarged or cryptic tonsils.2 In a later study in Connecticut along the same lines different results were obtained. This investigation, made during a thyroid survey, disclosed some degree of enlargement among 7 per cent of the 5,797 boys and 29.4 per cent of the 6,608 girls examined. Analysis of the data gathered showed that slightly and markedly decayed teeth, as well as hypertrophied and cryptic tonsils, were more frequently associated with thyroid enlargement than with normal thyroid conditions. Consequently it may be that oral prophylaxis is an aid in preventing thyroid enlargement. • Endemic goiter and physical development.—Inasmuch as many writers have reported that thyroid enlargement is associated with retarded physical growth, a study was made among Cincinnati school children to determine this point. Ten uniform measurements were made of each child included in the investigation. Despite obvious limitations, the study apparently showed that children with normal thyroid glands have a slight superiority in certain physical measurements. Consequently it may be assumed that thyroid-normal children are, to some extent, better developed. Thyroid-enlarged children, however, appear to have the advantage in slightly greater height, particularly in the sitting position. Endemic goiter and school absenteeism.—Records of absenteeism among a comparatively small number of children in the sixth grade and open-air classes of the Cincinnati schools disclosed much information of interest. In the group observed absence from school was slightly greater among the thyroid-normal children. Incidentally it was found that absence because of common colds was slightly more frequent among the girls. Contrary to the findings of other observers, the limited Cincinnati study showed that the average absence on account of common colds was slightly greater among the Reprint No. 1081 from the Public Health Reports, May 21, 1926. 2 Reprint* No. 1069 from the Public Health Reports, Mar. 26, 1926. PUBLIC HEALTH SERVICE 19 those in the children attending the open-air classes than among regular classrooms. representaConference of consultants.—In order that the service the experifrom t benefi may ns igatio invest goiter in ed engag tives constibeen has board ting consul a s, expert of ence and guidance York New of e, Marin tuted. This board, composed of Drs. David Salt of , Beatty B. T. and • Minn. ter, Roches of City; H. S. Plummer, this At s. e officer servic Lake City, Utah, had one meeting with the future for laid were plans and ted evalua session past work was activities. t knowledge Incidence of goiter in the United States.—Our presen is based States d Unite the in goiter ic endem of bution distri of the office of The . ations examin draft the of largely upon the results s of record with ation goiter studies is supplementing this inform reto on additi In s. source s variou from thyroid surveys obtained s were serecord onal additi many ture litera the in ys surve ports of ipal health cured by correspond.ng with all State, county, and munic and constited tabula being are data These y. countf the in officers ning intraconcer ble availa now n matio tute the most complete infor . goiter ic endem of bution distri tate inters as well state as eficiency iodine-d the of ation enunci Iodine determinations.—The health many of ion attent the ed direct has ion causat goiter theory of arCircul food. and water ing drink of officials to the iodine content ed a reveal ns inatio determ iodine ding regar s officer health ization of er, it is apgreat deal of interest and a few reports of results. Howev t are difficonten iodine g minin deter of ds metho t presen parent that only approxicult of application, require costly apparatus, and are al research is chemic ly quent Conse .. results their in te mately accura required to improve the situation. of goiter Goiter references.—An important function of the office inquiries ring answe of that is e stud'es of the Public Health Servic questions relating to various phases of the goiter problem. Theserange. In wide a have and ry count come from all portions of the ture is carefully order to meet this demand, the current goiter litera reprints have Many cted. abstra are s indexed and important article available for are and s article goiter of s author from ed been obtain reference. sion and In order to enlist the interest among the medical profes the secure to and y malit abnor ent health officials in this widely preval proced rable compa and rm unifo less or more by data collection of have ngs fic meeti scienti and sional ures, a large number of profes been addressed on the subject. INFLUENZA l The office of influenza investigations continued under the genera He 1926. year fiscal the g durin end direction of Surg. J. G. Towns man, was assisted by a board composed of Surg. W. H. Frost, chairr as tricke Sydens Edgar tician Statis with himself as member, and recorder. tabulaThe work was devoted chiefly to the editing, coding, and 1, 1925, July to prior ted collec ation inform of mass large tion of the of uation contin the to ts, e studen from approximately 14,000 colleg al medic of es famili in s attack atory respir of s record of tion the collec 20 PUBLIC HEALTH SERVICE officers of the United States Army, Navy, and Public Health Service. and members of the faculties of certain medical schools, and to the editing and coding of the records from these families which had been collected during the preceding year. The basic tabulations for the general results of this study have been completed for the college students and for medical officers for the year 1924 and partially corni-ileted for 1925. In the collection of these records and in their coding and tabulation prior to 1926 valuable assistance was rendered by the influenza commission of the Metropolitan Life Insurance Co. The case records obtained from college students in different localities are being utilized for two general purposes: (1) The records of 11,750 students, of cases occurring within the period October 1, 1923, to June 30, 1925, have been tabulated in order to determine the rates of prevalence for each diagnosis in the different localities, their seasonal variation, and the synchronism of their' short-time variations. The results of this analysis will be published in considerable detail, but it is of interest to note that there was a general similarity in the rate of prevalence in each locality and that the major variations in incidence in widely scattered localities were synchronous,thus confirming the indications referred to in a previous reportwhich were based on a preliminary and partial tabulation. (2) The case records of about 2,000 individual students were subjected to a more detailed analysis. These individuals were selected because of the regularity and continuity of their reports and becausethey remained throughout the calendar year 1924 in the same localities. The principal objectives of this study were to determine as definitely as possible to, what extent the cases reported under different diagnoses, such as colds, bronchitis, sore throat, influenza, etc.,, were clinically differentiated; to compare the symptomatology for each diagnosis in different localities and at different seasons, and also with respect to the duration of illness, the gross attack rate, and seasonal distribution; and to correlate the frequency and severity of the attacks with certain facts in the previous history of the individual. This tabulation has been practically completed and thepreparation of a report is now under way. The reports from the families of medical officers of the Army,. Navy, and Public Health Service and of members of the medical faculties in certain universities were discontinued on June 30, 1926. They were begun in the latter part of 1923 and thus cover more than two complete years. In view of the facts that about 1,500 such fami-lies reported with a fair degree of regularity throughout the period,. that they were persons of both sexes and all ages, and that the diagnoses were made by medical men in practically all instances, these records are believed to be exceptional'in the epidemiological study of respiratory diseases. The preparation of the records for the year 1924 for tabulation has been completed. It is expected that the remainder of the records will be ready for tabulation within a few months. In these families the incidence rate during 1924 of all respiratory attacks was 2.02 per person. Expressed as rates per thousand persons observed for a period of one year, the incidence of 5,052 attacksclassified according to diagnosis among persons of different sexes was, as follows: 21 PUBLIC HEALTH SERVICE TABLE 1.—Incidence of respiratory attacks of different types in families of medical officers of the U. S. Army, Navy, and Public Health Service during 1924 Rate per 1,000 in 1924 Diagnoses Both Males sexes All respiratory attacks "Colds" in head or nose Bronchitis Tonsillitis, pharyngitis, and sore throat. Influenza Hay fever 2,022 1,519 161 141 183 25 Females 2,089 1,564 175 140 194 22 1,961 1,476 148 142 174 29 VARIATIONS ACCORDING TO ACE OP RESPIRATORY DISEASES IN FAMILIES or MEDICAL OFFICERS OF ARMY, NAVY, AND FOLIC HEALTH SERVICE DIMING 1924 10 20 1 1 Age 30 1 40 50 60 10 20 1 i 1 I 1 Age 30 40 1 1 All Respiratory All Ages = 1519 per 1,000 1.0 I Bronthitis -- 2.5 Sore Tbrost LA ;'.73 ti5 0 1 I - —1.5 ;.) All Ages.161 per 1,000 Alk All Ages ./41 per 1,000 ,- , • o I _ . 60 I Colds All Ages.2022 per 1,000 Ratio of the Rate at a,,pecified. Age Period to That for All Agez 50 1.0 -- .5 1 1 1 I I Ray Fever All Ages - I ! 1 1 Influenza 25 per 1,000 0 -- 1.5 1.0 = 183 per 1,000 o .5 10 20 30 40 Age 50 60 10 20 40 30 Age 50 60 The tabulations of the 1924 experience of this population show the age incidence of respiratory attacks of different kinds. A more complete report is in process of preparation, but the diagram shown above may be of special interest. 22 PUBLIC HEALTH SERVICE The age curves shown in this diagram may be regarded as characteristic of all diagnoses with the exception of tonsillitis, since similar curves have been indicated for comparable diagnoses from statistics obtained from entirely different sources by the offices of child hygiene, industrial hygiene, and statistics. The characteristic tonsillitis curve, as determined by these other sources of information, shows that tonsil defects and tonsillitis are confined almost entirely to persons of younger ages; the curve shown in the accompanying diagram for tonsillitis and sore throat, however, is not inconsistent with the other results because of the relatively low prevalence of tonsillitis in this particular group of persons who have been tonsillectomized to an unusual extent. The differentiation of attacks classified by medical officers under the different diagnoses is especially interesting from the point of view of their symptomatology. In the accompanying table the frequency of 13 specified symptoms is shown for each diagnosis.. The results may be regarded as confirming the generally accepted clinical descriptions orthe diseases specified, although they do not establish definitely characteristic syndromes. The generalized symptoms such as fever, chill or chilliness, aching in body and limbs,, sudden onset, constipation, and headache are fairly closely correlated,. appearing with greater frequency in attacks diagnosed as influenza than in other attacks, while the specific local symptoms appear most frequently in attacks diagnostically differentiated as head colds, bronchitis, and sore throat. TABLE 2.-Frequencies of 13 specified symptoms in respiratory attacks of different types, as recorded by medical officers of the United States Army, Navy, and Public Health Service, for cases occurring in their families. during 1924 5,210 cases of"colds" Symptoms Running nose of Obstruction nostrils Cough Sudden onset Headache Sore throat Expectoration_ _ _ _ Aching in body or limbs Fever Inflammation of eyes Constipation Tightness in chest_ Chill or chilliness__ 489 cases of bronchitis with cough Per cent Symptoms 81.4 Cough Expectoration Tightness of chest Sudden onset Fever Running nose Sore throat Aching in body or limbs Headache Obstruction of nostrils Constipation Inflammation of eyes Chill or chilliness_ 48. 1 42.8 40.4 22.6 22.5 20. 5 18.0 17.9 12.0 11.5 10.8 4.5 497 cases of sore throat ' t onsilli tis, and pharyngitis Per cent Symptoms 91.0 42.7 36.6 35.6 29.0 29.0 17.8 Sore throat Sudden onset _ _ __ Fever Headache Aching in body or limbs Cough_ Constipation Expectoration Running nose Chill or chilliness_ Obstruction of nostrils Tightness in chest Inflammation of eyes 16.8 16.6 16.4 13. 7 10.4 6.5 599 cases of influenza or grippe • Per cent Symptoms 82. 5 45.1 41.9 31.2 Fever Aching in body or limbs Sudden onset Headache Running nose Cough So o throat Obstruction of nostrils Constipation Expectoration Tightness in chest_ Chill or chilliness_ Inflammation of eyes 29.0 26.0 17. 5 13. 5 12.5 11.7 8.2 5.8 3.4 Per cent 75.6 69.9 59.6 58.8 56.8 54.8 39.6 39.4 27. 5 26. 4 26.0 25. 7 18.0 A report embodying the results of the studies outlined above is in preparation and will be presented during the coming year. Upon the completion of this report it is planned to analyze the data further for the purpose of carrying on certain more specific inquiries, such as the determination of whether or not any association exists between short-time variations in the incidence of re- PUBLIC HEALTH SERVICE 23 spiratory attacks of different types and variations in the meteorological conditions in the same localities, the relationship, if any, between the respiratory attacks experienced by various individuals during the period of record and previous history of respiratory attacks, of dietary habits, and of physical exercise. A large number of the family records are being studied from the point of view of the sequence of cases at different times of the year and in periods of apparently epidemic and nonepidemic conditions. LEPROSY INVESTIGATION STATION Surg. M. H. Neill continued as director of the leprosy investigation station, with headquarters at Kalihi, Honolulu, near the Territorial Hospital for Lepers. Medical treatment of these patients was furnished by officers from the investigation station and research work on some of the problems of leprosy was conducted. The University of Hawaii has continued its generous policy of furnishing space in its chemical laboratory for the manufacture of chaulmoogra derivatives for the treatment of leprosy and for the preparation of new compounds under the supervision of its chemists. Clinical observations.—There were 130 patients in the hospital July 1, 1925. During the year 91 patents were admitted, 17 were paroled, 3 died, and 42 were transferred to Molokai. The number of patients in the hospital at the close of the year was 159. Twenty of the cases admitted during the year were returned parolers. During the period July 1, 1921, to June 30, 1925, the yearly average admission was 95.5. Classifying into early, moderately advanced, and advanced stages of leprosy, the results were as follows: Early, 12; moderately advanced, 44; advanced, 39.5. Durfng the past year 15 early, 43 moderately advanced, and 33 advanced cases were admitted. For the fiscal year 1925-26 the distribution was as follows: Hawaiian Japanese Part Hawaiian Chinese Filipino Chinese-Hawaiian Portuguese German Porto Rican Japanese-Hawaiian Scotch Total 33 12 10 9 9 9 4 2 1 91 Sixty-seven of the admissions were males and 24 were females. In 7 of the 17 persons paroled during the year the leprosy bacillus was never detected. It has been present in the remainder. The average duration of segregation for the parolers was one year and nine months. Ten were males and seven were females. During the past five years, in order to obtain parole a patient must have shown absence of leprosy bacilli for three successive examinations at three months' intervals and have shown no clinical evidence of activity during the same period. From September 1, 1920, to September 1, 1924, 394 cases of leprosy were admitted.. Up to the 24 PUBLIC HEALTH SERVICE present time 133, or 33.75 per cent, have been paroled and 29, or '21.80 per cent of those paroled have returned to segregation. The treatment of practically all patients with weekly intramuscular injections of from 1 to 3 cubic centimeters of the mixed ethyl esters of chaulmoogra oil, plus one-half of 1 per cent iodine added to the esters before sterilization, has become a well-established routine at this station and has been continued both in the hospital and for the treatment of paroled persons. Some cases have been treated with iododihydrochaulmoogric acid, the preparation of which was mentioned in the previous report. A recrudescence of cutaneous symptoms followed its use in most instances, possibly on account of its high iodine content. During the year 219 patients in the hospital received a total of 5,575 intramuscular injections; also 173 paroled patients received 2,354 treatments at the out-patients' department at Kalihi Hospital or by Territorial physicians on other islands. Studies of the effect of radium on the leprous lesions of the nose have been completed. There were 32 cases treated with radium and 21 lepers observed as controls. It was concluded that radium was generally effective in removing the nodules of leprosy from the nasal cavity; that it was not a reliable accent for ridding the nose of leprosy bacilli; and that it should only be used in the nose when special indications exist. Its use as a routine is not advised, the more so as septal perforations were not uncommon after its use. Studies of the leprous lesions of the eye have been inaugurated by Dr. F. J. Pinkerton, opthalmologist to lepers for the Territorial board of health. Especial attention has been given to the effects of plastic operations on the lids. A study of the best methods of dealing With perforating ulcers of the feet has been made and improvement in technique has resulted. The records of 405 lepers admitted to Kalihi Hospital were analyzed, with special reference to the presence of thermoanesthesia independent of definite lesions of the skin. Tests were made of the disturbance of hot and cold sensation along the external margins of hands, forearms, feet, and legs. The following table gives information of some degree of thermoanesthesia in these regions among the following groups of lepers: Thermo-anesthesia among groups of lepers Neural Nodular Early Present Absent Total Per cent present 8 3 Mixed ModerModerModerAdately AdAdately Early ately Early ad- vanced advanced ad- vanced vaneed vanced vanced 24 9 41 11 29 6 66 5 35 1 9 3 79 5 70 11 33 52 35 71 36 12 84 71 72.7 72.7 78.8 82.8 92.9 97.2 75 94 98.5 As might•be expected, the largest percentage showing some thermoanesthesia occurred among the well-marked cases of neural and 25 PUBLIC HEALTH SERVICE mixed leprosy. However, it is important to note that 75 per cent of those classified as nodular lepers showed disturbances of hot and cold sensations somewhere in the distribution of the ulnar and internal cutaneous, or peroneal and external saphenous nerves. This serves to illustrate the fact that demonstrable involvement of the • nervous system is present in the great majority of lepers. In our experience at Kalihi involvement of the nervous system occurs more frequently than does the demonstration of the leprosy bacillus at entrance, which was found in only 63 per cent of lepers admitted during the period of study. It may be stated that the procedure in vogue for segregating lepers in Hawaii makes the possibility of the entrance of a nonleper to Kalihi Hospital very remote. During the year a study of the protef.n constituents of the blood in leprosy has been made. A review of the literature reveals that few extensive studies of this nature have been made on persons ill of infectious diseases since the adoption of accurate laboratory methods. About 150 tests on lepers have been made, 50 tests on normal soldiers, and a number of tests on individuals sick with typhoid fever, pneumonia, and tuberculosis. The data obtained are in process of analysis. A number of attempts have been made to cultivate leprosy bacilli obtained by incising the skin of lepers. Partial tension methods and a variety of media containing different amino-acids were used. Rigorous precautions were observed against introduction of contaminating organisms. No proliferation of leprosy bacilli was observed, although they were proved present in abundance on the culture media. The preparation of special chaulmoogra derivatives has been given less prominence than in former years on account of the rather unsatisfactory therapeutic results from the ethyl esters of chaulmoogra oil. The preparation of chaulmoogryl alcohol, however, has at least considerable academic interest. This has been accomplished by the reduction of ethyl chaulmoograte with sodium. Several reports from the Orient have been received of the substitution of oils derived from Hydn,ocarpus wigh,tiana and Hydnocarpus anthellnintica for chaulmoogra oil from Taraktogenous kurzii in the therapeutics of leprosy. Samples of these hydnocarpus oils have been obtained. They appear to be equal in chemical reactions and superior in physical properties to chaulmoogra oil. What, if any, therapeutic effect these oils may have in leprosy remains to be determined by clinical trial, now begun. The following amounts of the mixed ethyl esters of chaulmoogra oil have been prepared and distributed as follows: Ethyl esters manufactured Balance on hand June 30, 1925 Amount distributed to— Kalihi Hospital Board of health Cuban consul Balance on hand June 30, 1926 14656-26-3 Cubic centimeters 28,250 6,000 34,250 21,000 5500500 27,000 7, 250 26 PUBLIC HEALTH SERVICE Epidemiological studies.—During the year a statistical study was completed of the occurrence of leprosy in families some of whose members entered segregation 1911-1920. For the purposes of this study only members of families, viz, father, mother, husband, wife, brother, sister, son, and daughter were considered. The records would not justify a study of other relationships. During the period 1911-1920 representatives of 742 families were declared lepers. The records indicate that there were in these families 3,662 nonleprous relatives resident in Hawaii. During the period 1911-1925,.167, .or 4.56 per cent, of these relatives were declared lepers. The attack rates among the relatives were as follows: Sons or daughters, 6.35 per cent brothers or sisters, 5.47 per cent husbands or wives, 2.45 per cent mothers or fathers, 1.48 per cent. One hundred and forty-nine, or 89.22 per cent, of all secondary cases segregated occurred among the sons or daughters or brothers and sisters of first cases segregated. Of 121 families with more than one case entering segregation 1911-1925, 112, or 92.56 per cent, were Hawaiians or part Hawaiians. The census of 1920 states the Hawaiian and part Hawaiian population of the Territory to be 41,750. During the period 1911-1925 there were 814 persons of Hawaiian blood entering segregation, or an attack rate of 1.95 per cent. Thus it would appear that the attack rate in leper families is somewhat more than twice as great as in the general population of a similar race—that is, Hawaiian or part Hawaiian. The total population of the Territory for 1920 was 255,912. During the period of 1911-1925 there were 1,161 new cases of leprosy recorded or 0.45 per cent of the general population. According to this comparison, the incidence of leprosy was ten times as great among the relatives of lepers entering segregation 1911-1920 as among the general population. The following table gives information as to the children living with lepers segregated during the year. What proportion of these will eventually develop leprosy is an interesting speculation. Number of patients admitted to Kalihi Hospital from July 1, 1925, to June 30, 1926, having children in h,ouseha1d Patients with children Patients without children Patients without data 62 27 2 Total 91 Number of children 181 Age of children Age (years) Male Female Total 0-5 5-10 10-15 16-20 31 25 21 12 28 30 16 18 59 55 37 30 89 92 181 Total____ PUBLIC HEALTH SERVICE 27 Acknowledgement is made to the Territorial board of health for providing radium for the treatment of nasal leprosy. MALARIA The study of the malaria problem of the United States was continued during the year under the general direction of Surg. L. D. Fricks, with headquarters at Memphis, Tenn. From the initiation of these studies in 1914 it has been the policy of the service to undertake first the solution of the most serious and practical problems, leaving minor and less pressing subjects for future development. The extent of the malaria problem in the United States has permitted such selection, and the character of the malaria allotment has rendered it necessary. It is a source of gratification, therefore, to report that two important malaria problems so nearly reached the point of solution during the year that their further study was discontinued and other subjects were substituted for them in the program of malaria investigations. These were epidemiological studies of malaria and studies .of fish control of mosquito production. Other major malaria studies which are being continued include rural malaria control, Anopheles habits, larva foods, larvicides, impounded waters in relation to malaria, screening, and drainage. Epidemiological studies of malaria.—The great difficulties attending the problem of when, where, and under what circumstances malaria is occurring in the United States have always been recognized by public-health officials. In 1921 the service began a determined effort to solve the major epidemiological problems of malaria in the United States. An officer especially trained in epidemiological methods was assigned to these studies, which have been continued for five years. A careful study of malaria morbidity and mortality reports in the Southern States was made; the State health departments concerned were assisted in correcting faulty reporting of malaria and improving their methods of collecting malaria statistics. Special surveys of endemic malaria centers and epidemics of malaria were made from time to time. More than 20,000 school children in 11 Southern States were examined for evidences of malaria infections, including histories of previous infection, enlarged spleens, and blood for malaria plasmodia. In connection with these studies and as an aid to accurate diagnosis 9,106 blood smears were examined for malaria parasites during the year. P. vivax was found in 254 of these, P. faleiparum, in 433, P. malariae in 2, and both P. vivax and P. faleiparwm, in 2. As a result of these studies the following general conclusions have been reached: A great reduction in malaria prevalence has taken place in the United States within the past 50 years. The rate of malaria reduction has increased in the last half of this period. At the present time malaria is practically confined in its distribution to the South Atlantic coastal plain, the Gulf coast, and the lower Mississippi Valley, and even in these regions the distribution of the disease is focal in character. In localities where malaria was formerly prevalent many minor ailments are still called malaria—this is the "traditional" malaria so commonly encountered throughout the 28 PUBLIC HEALTH SERVICE South. Areas of high-malaria prevalence are found chiefly along the river bottoms and around swampy areas in the Southern States. Should the same reduction rate as that noted during the past five years continue, malaria will cease to be of public-health importance in the United States within the next 50 years. Fish, control of mosquito production.—In 1918 the Bureau of Fisheries and the Public Health Service undertook a cooperative study of this important subject. Ichthyologist Samuel F. Hildebrand was detailed by the Bureau of Fisheries to make this study, and many observations were contributed by the malaria field personnel of the service. ,The investigation was continued each summer through 1925, when it was discontinued as having been practically completed. During the course of these studies observation stations were located at Augusta and Savannah, Ga., and in the summer of 1925 at Greenwood, Miss., and, in addition, numerous fish surveys were made of impounded waters, natural ponds, and streams from Virginia to Texas. All larva-eating fish of this region were investigated and a thorough study of the life history and habits of Gambusia affinis was made. Many important new facts were discovered concerning this little fish. The general conclusions of these cooperative fish studies are as follows: Gambusia allinis is the most efficient of the American fishes in the control of mosquito production. Mosquito larvae constitute a large part of its normal food. It is viviparious,• propagates rapidly, and can be transported even for long distances with ordinary care. For these reasons, under favorable conditions Gambusia affinis will control mosquito production. Where conditions are less favorable much can be done by cleaning away flotage and vegetation and by protection from larger 'fish to make Gambusia effective in destroying mosquito larva. Gambusia, however, can not be depended upon to control mosquito production in all bodies of water under all conditions. They should be employed intelligently, as should all antimalarial measures, and given help when needed. As a result of these fish-control studies Gambusia hatcheries have been established by State and local health departments, industrial corporations, and private individuals throughout the Southern States, and shipments of Gambusia have been successfully made to California, Spain, Italy, Yugoslavia, Greece, Palestine, the South American countries, and Hawaii, where they are being used to destroy mosquito larva. Studies of rural malaria control.—The practical objective of all service malaria investigations has been the control of malaria in the United States, which, in the last analysis, means rural malaria control. During the fiscal years of 1924 and 1925 rural malaria-control studies were conducted on an extensive scale in many Southern States, with service officers cooperating with county health officers in locating malaria foci and observing the results of malaria-control measures selected as suitable to local conditions. At the beginning of the fiscal year 1926 it was necessary to transfer these field officers to other public-health activities, and hence these studies of rural malaria control were greatly restricted, being confined this year to six counties in Virginia and one county in Mississippi, and surveys of particular rural malaria control problems as made from time to PUBLIC HEALTH SERVICE 29 time from malaria field headquarters at the request of State and county health officers. The study of malaria in Leflore County, Miss., is of peculiar interest in that a typical county of the Mississippi Delta, that region of the United States in which malaria is now most prevalent, was selected. An officer was stationed in this county and given opportunity to keep in close touch with the malaria situation and study the changes in malaria prevalence which may take place from year to year. Thus by making an intensive study of a typical county over a period of several years it is expected that this office will be able to measure the fluctuations in malaria which occur and determine the causes which produce them and then apply this information to the control of malaria el,sewhere in•the United States. Studies of anopheline mosquitoes.—Two field laboratories were operated during the year, one at Savannah, Ga., and one at Greenwood, Miss., for study of anopheline mosquitoes in their natural environment. Associate entomologist Bruce Mayne directed the Savannah laboratory and made special observations of A. erucians in relation to malaria transmission. A survey of the Okefenokee Swamp' in south Georgia was made by Mr. Mayne. In the territory of the swamp,embracing approximately 720 square miles, more than 10,000 mosquitoes were examined and all identified as A. erucians. No malaria was found in this locality, where only A. eracians were present, although the mosquito infestation was enormous. Mr. Mayne also made a mosquito survey around Lakeland, Fla., finding some infected A. quadrimaculatus and no infected A. cructans. In these surveys no positive evidence was found incriminating A. crucians as a malaria vector. It must be remembered, however, that A. crucians infected with malaria plasmodia have been found in nature. An extensive series of observations dealing with Anoph,eles production, habits, and destruction have been conducted under the direction of Dr. M. A. Barber from the Greenwood, Miss., field laboratory. Studies of egg hatching and larva development as influenced by pH concentration and the study of the influence of larva foods upon development have been carefully and thoroughly conducted. A large number of larvicides have been tested and their relative values established. The most satisfactory Anopheles larvicide discovered by Doctor Barber is Paris green,first used for this purpose and reported on by him in 1921. Further studies of Paris green have only confirmed and extended its usefulness as an Anopheles larvicide. Doctor Barber was requested to visit southern Italy and Yugoslavia in the late summer of 1925 in order to inspect the Paris green larvicidal work which was being done in those countries and give advice concerning the use of this larvicide. Owing to the restricted 'Mosquito-producing areas in those countries as compared with the southern United States it was found that Paris green has proved even more successful there than with us, and it appears possible to control absolutely Anopheles production in southern Italy and Sicily by this measure alone. Around Quantico Marine Barracks an investigation is being made of the efficiency of Paris green as an Anopheles larvicide when spread from an airplane. In the Potomac River, just off the barracks, large 30 PUBLIC HEALTH SERVICE masses of floatinc,eeloTass (Zostera marina) are found. These produce anopheline mosquitoes in enormous numbers, and heretofore no feasible method of controlling mosquito production in them has been known. The Chopawamsic swamps near by are almost as inaccessible as the floating islands of eelgrass. Apparently an easy, inexpensive, and effective.method of destroying Anopheles larve in these Inaccessible areas has been discovered in Paris green spread from airplanes. Malaria and mosquito surveys have been made throughout the year in Leflore County, Miss., by the personnel of the Greenwood laboratory. The data gathered will be of great value as a part of the study of rural malaria control in Leflore County. A malaria survey of the negro population of Gary, Ind., was made in September, 1925. One hundred and seventy-four persons were examined, of whom 14 were found to have malaria parasites in their blood. This is an interesting finding in view of the extensive movement which has taken place of negro farm labor from the South to northern industrial centers. ' In a malaria survey of 47 Mexican cotton pickers recently arrived in Mississippi from southwest Texas it was found that 10 of these Mexicans had malaria parasites in their blood. This survey is of interest to State health officials and to the general public because of the frequent and extensive movement of farm labor in the southwestern part of the United States. Studies of impounded waters.—Studies of impounded waters in relation to malaria were continued during the year. A detailed study of the impounded water malaria problem of Alabama was completed at the beginning of the year. In this study an officer was assigned to keep under continuous surveillance a series of impounded waters in Alabama having different physical and biological characteristics. Anopheles production in these lakes was studied and suitable measures of control were developed. In connection with these studies an apparatus for spraying oil under pressure by means of precharged compressed air tanks was devised. This apparatus will effect a great saving in time and labor on large impounded water projects. The officer in charge of these studies also cooperated with the State health department in enforcing the State regulations' governing impounded waters. In this way it was possible to estimate the value of these regulations in the control of malaria and make practical suggestions as to their enforcement. In the tidewater region of Virginia 13 small impounded lakes or ponds were used experimentally to determine the feasibility of controlling mosquito production by fluctuation of the water level. The water level in these ponds was lowered from 12 to 18 inches at successive intervals, and by this means the shore lines of the ponds were kept relatively free of vegetation and stranded debris. As a result mosquito production along the margin of the ponds was greatly reduced. It was found that in this type of pond, where there is little flotage or aquatic vegetation scattered over the surface of the pond and where consPquently, mosquito production is confined to the margin of the pond, fluctuation intelligently employed is a valuable means of mosquito control. At the request of the State health officers concerned, Senior Sanitary Engineer J. A. be Prince from time to time inspected a number PUBLIC HEALTH SERVICE 31 of large impounded water projects in Virginia, North Carolina, South Carolina, Georgia, Tennessee, and Missouri. These impounded water projects have been established either for the development of hydroelectric power or in connection with city water supplies in Southern States. Advice was furnished to the State health officials and to the developmental agencies as to the proper precautions which should be taken to prevent Anopheles production and malaria transmission around these artificial lakes. The rapid progress Which has been made in the development of hydroelectric power in the Southern States during the past 10 years has been accelerated by the studies which the Public Health Service has made of impounded waters in relation to malaria. The general principles involved in the control of mosquito production in impounded waters have been determined and have been embodied in State health department regulations of the Southern States in which the impounding of water on a large scale is being undertaken. Drainage studie8.—Elimination of Anopheles breeding places by, proper drainage has been one of the major malaria problems investigated by the service. Major drainage, minor drainage, vertical drainage, subsoil drainage and construction and maintenance of drainage ditches have all been studied by service investigators, and generally satisfactory although not absolutely final conclusions have been reached in regard to these matters. During the past year, because of limited personnel, drainage studies were confined to the subject of vertical drainage in the Mississippi Delta region. It has been shown that in limestone regions vertical drainage can be frequently employed effectively and at a very small cost as compared with the cost of surface drainage. Often by boring a hole 10 to 12 feet deep in a limestone sink and exploding a charge of dynamite at the bottom of the hole a seam can be loosened in the bedrock and efficient drainage provided at a very small cost. During the past year observations were made in the Mississippi Delta with a view to determine whether the same principle of vertical drainage might be employed in this region. Test holes 4 to 6 inches in diameter were bored reaching down to the water bearing sand stratum. Usually a depth of from 15 to 20 feet was required. These shallow wells were located in proximity to a small body of water, and effort was made to secure drainage of the water through the well into the porous sand below. The results of these observations so far have not been encouraging. Screening studies.—Studies of the value of screening as a protection against malaria in rural communities of the Southern States and the most practical means of accomplishing it have been continued in Leflore County, Miss. Data so far collected indicate that in areas of high malaria prevalence families living in unscreened that homes have more malaria than those living in screened homes, greater the economic loss to the tenant families from malaria is on than the cost of screening, and that the care given to the protecti greater much is home of screens on an average negro farm tenant material than is, usually expected. Various qualities of screeninglongevit y, are being studied in order to determine their efficiency, screens, door and window of types t Differen and relative cost. varydifferent methods of fitting them, and the relative efficiency of ion. observat under are d employe g ing the amount of screenin 32 PUBLIC HEALTH SERVICE The farm-labor shortage situation in some sections of the South has become acute. In some counties the labor shortage has interfered with the gathering of farm crops, resulting in a considerable loss. Malaria contributes greatly to inefficient labor and plays an important part in this loss. To combat this unsatisfactory situation numbers of Mexican laborers are now being employed, following the ripening crops from southwest Texas as far east as Mississippi. This migratory farm labor may becbme an important factor in the spread of malaria even into localities where malaria does not now prevail. For all of these reasons the study of screening of farm houses as a protection against malaria and the consequent improvement of living conditions in the farm home are of great importance to the welfare of the South and to the United States at large. Detailed reports relating to these studies have been published from time to time and form a part of the service malaria literature, which is in great demand by those who are interested in the malaria problem of the United States. N u TRITIONAL DISEASES The very important subject of human nutrition is being approached from many different angles at various research institutions throughout the world. It happens that the Public Health Service has access to exceptional facilities for the investigation of one major nutritional disease, and, as in the past few years, it has continued to utilize these facilities during the year just closed, chiefly in investigations of pellagra. The Facts revealed by these studies are of an interest far beyond the limitations of the disease in question. Two contributions of general interest have been made during the past year: One, that a dietary factor hitherto considered as homogeneous is in reality probably composed of two distinct agents, a piece of information which may elucidate some formerly puzzling data the other, that the white rat is apparently admirably adapted to nutritional studies of pellagra. This discovery should give impetus to such studies, since these animals are relatively cheap, easily kept and handled, and can be conveniently used in greater numbers than the larger animals hitherto employed. The field studies were, as for some years past, actively carried on under the direction of Surg. Joseph Goldberger, at the Georgia State Sanitarium, Milledgeville, Ga., and in cooperation with the Hygienic Laboratory at Washington, D. C. At the Georgia State Sanitarium studies were conducted of the pellagra-preventive value of tomatoes, carrots, and rutabaga turnips. The results of these studies will be made the subject of a special report. At the Hygienic Laboratory the study of experimental black tongue was carried on throughout the year, with special reference to its relation to human pellagra by testing the black-tongue preventive activity of a number of foods. The results continue to indicate that this pathological condition of the dog and human pellagra are fundamentally identical conditions. In connection with the studies of black tongue a large number of experiments were carried out in the albino rat with results indicat- PUBLIC HEALTH SERVICE 33 ing that the dietary factor that prevents pellagra and black tongue— which for convenience has been designated as factor P—P—is, as it exists in yeast, quite thermostable and is probably identical with a factor that has heretofore been included with the antineuritic or beriberi factor, in the designation "water soluble B." Or, in other words, that the vitamin heretofore known as water soluble B actually includes two vitamins, one the antineuritic or beriberi vitamin which, as it occurs in yeast, has been found to be relatively readily damaged or destroyed by heat, and the other the newly recognized factor P—P above referred to. In the studies in the albino rat there were included also tests of certain diets that were so constructed as to be deficient in factor P—P, but complete for growth with respect to all other at present known dietary essentials. Among the animals fed these diets a number developed a condition strikingly suggestive of pellagra and, so far as can at present be judged, is very probably the analogue of black tongue in the dog and pellagra in man. The results of the laboratory studies indicate therefore that both the dog and the albino rat are suitable experimental animals for the study of pellagra. Further studies will be required, however, to establish this beyond question. Some of the results referred to in the foregoing have been the subject of special reports which have been published during the year.3 The office of nutrition investigations has, in addition to its research activities, replied to a large number of inquiries from the public on various nutritional problems. ROCKY MOUNTAIN SPOTTED FEVER The studies of Rocky Mountain spotted fever have been continued at the Hygienic Laboratory, under the direction of Surg. R. R. Spencer, and at the field station at Hamilton, Mont., under the direction of Special Expert R. R. Parker. The major effort of the year has been expended in the preparation of the prophylactic vaccine which has been developed against Rocky Mountain spotted fever, in the testing of its value by administration in selected areas, and in the checking of results. Its probable effectiveness as a preventive agent had been indicated by the results of a preliminary test made in 1925 in a group of persons exposed to constant and unusual danger of infection. Two men who had received but one-fourth the dosage considered likely to give full protection later contracted mild infections and recovered. These recoveries were the only two among seven Bitterroot Valley cases during the season of 1925, and also the first two records of recovery among laboratory and control workers. Although somewhat curtailed because of the importance of the vaccine work, other lines of the Rocky Mountain spotted-fever investigations have been continued, as follows: Field investigations relating to the means of maintenance and perpetuation of Rocky Mountain spotted fever in nature; epidemiological studies relating particularly to distribution and prevalence; laboratory studies of the Reprints Nos. 1062 and 1083 from the Public Health Reports for Feb. 19, 1926, and May 28, 1926. 14656-26---4 34 PUBLIC HEALTH SERVICE tick and blood virus of Rocky Mountain spotted fever and further studies on tick. paralysis. Preparation of vaccine.—The production of the vaccine, which is made from infected adult ticks, requires nearly a full year. It involves the engorging of hundreds of female ticks, the feeding of hundreds of thousands of the resultant larvw on infected hosts, and the rearing of these through the nymphal stage to adults. It is in the adult ticks that the highly virulent virus essential for a potent vaccine most consistently occurs. The degree of virulence, however, varies markedly in the progeny of different parent females, and for this reason it is necessary that the progeny of each female be reared to adults and later made into vaccine as distinct units. This greatly increases the labor involved. The rearing and infecting of the ticks and the making the vaccine in bulk has been done at Hamilton, Mont. It was then forwarded to the Hygienic Laboratory, where each lot was tested for sterility and potency, freed of tick tissue, and the completed product jut in ampules ready for use. Tests to detemine effectiveness of vaccine.—Tests of the vaccine during 1926 were planned on as large a scale as commensurate with the available vaccine. To this end, two areas were selected—one including territory tributary to Shoshone, in the Snake River Valley of southern Idaho, the other the Bitterroot Valley of western Mintana. These areas were selected with the object of determining (a) whether the vaccine were sufficiently potent to confer full immunity, or (b) if full protection were not given, to what extent the vaccine modified infection. The Shoshone area was selected not only because of the considerable number of cases that occur each year but also because so high a percentage of them occur among men engaged in handling sheep on the range, thus making it feasible to limit the test to a relatively small group of men in one industry. The number of nonimmunes,so employed was about 300. Of this number 123, or approximately 40 per cent, were vaccinated. The remaining 60 per cent served as controls. An absence of cases among the vaccinated group and a considerable incidence in the unvaccinated group would be strong evidence that vaccination had resulted in full immunity. If cases occurred in both groups, however, the test would mean little, since the marked variations in the severity of individual cases of the disease in this area would prevent definite conclusions as to partial protective value. This test was made with the cooperation of the Idaho Department of Public Welfare and the Idaho State Board of Sheep Commissioners. In the Bitterroot Valley, cases, while not numerous, are almost uniformly fatal. In this area, which is much smaller and has no outstanding type of agriculture in which cases predominate, it was planned to vaccinate the largest number of persons possible. Because of relatively low incidence, an absence of cases in the vaccinated group, except as continuing over a series of years, would be only of suggestive value. If, on the other hand, several cases occurred in this group and uniformly recovered, it would indicate that the vaccine conferred partial protection. If such cases, however, were fatal, vaccination would appear to be without value. A total of 620 vaccinations were made. PUBLIC HEALTH SERVICE 35 Results of tests.—No cases of spotted fever have occurred in vaccinated persons in either the Shoshone or the Bitterroot Valley Areas. In the former there have been 8 cases in the nonimmune control group of persons engaged in the sheep industry and 16 additional cases have occurred outside the control group. In the Bitterroot area there have been four cases, all of them fatal. These results are very suggestive of the value of vaccination and indicate that full immunity is conferred. The evidence, however, is less decisive than hoped for because of the unusually low incidence of cases, especially in the Shoshone area. It will be necessary to have a much larger volume of field data before any conclusion is reached. As a result of the tests made in 1925 and 1926 a very pronounced belief in the value of the vaccine is prevalent among the local physicians and residents of both test areas. It has been impossible to meet the demand for vaccine, both from within and without these areas. Persistent requests from Wyoming, due to increased incidence and mortality rate, have had to be refused. Indications point to a 1927 demand that will be greatly in excess of any supply that can possibly be prepared with present facilities. Field investigations.—Pertinent data relative to the factors concerned in the maintenance of spotted-fever infection in the Bitterroot region have been secured. These data indicate that the further prosecution of this phase of ,the investigation work, which has in view the application of findings to control methods, should proceed along two main lines: First, the securing of more comprehensive knowledge of the habits and the relative importance as wood tick (Dermacentor andersoni) hosts of the various mammals which inhabit the Bitterroot Mountains; second, to determine the exact part which the rabbit tick (Haemaph,ysalis leporis-palustris) plays in the natural maintenance of infection. The first line of study is essential, because it has been demonstrated that the primary conditions responsible for the perpetuation of infection are resident in the west side mountains, and that any control procedure that aims at more than partial and temporary relief of valley conditions must include some plan for preventing or materially decreasing the annual outflow of infection from mountains to valley. The second is essential because the degree of thoroughness of wood-tick control necessary to eliminate valley infection or to reduce it to an irreducible minimum, and the nature and comprehensiveness of the measures which must ultimately be adopted to give permanence to the results secured, will hinge upon whether or not the rabbit tick can maintain infection independently of infection in the wood tick. Studies of tick and blood virus.—Studies of tick virus have demonstrated that the virus is inseparable from the red and white blood cells by laboratory methods but that the excrement of infected ticks is sometimes infectious. Infection has been recovered only from the intestinal excreta and not from the waste passed from the Malpighian tubules. Tick excreta heretofore has not been considered a source of danger. These Pesults, however, indicate the possibility that human infection can be acquired through tick excrement, although infection as thus transmitted to laboratory animals seems less virulent than when conveyed by the tick bite. Studies have also shown that the demonstration of Rickettsia in ticks is not conclusive proof of the infectiousness of such ticks. 36 PUBLIC HEALTH SERVICE Epidemiological studies relating to distribution and incidence.— Since this station was established in 1921, data have been accumulated which show an intensive and extensive spread and an increasing incidence of Rocky Mountain spotted fever throughout a large part of the infected areas in the Northwest, especially in the States of Wyoming, Oregon, Montana, and parts of Idaho. North Dakota has been added to the list of States in which the infection is endemic. Reports from many localities are suggestive of increasing virulence and a corresponding increase in mortality. This infection is certainly a factor of growing importance in the economic life of many sections of the Northwest. Incidental to the spotted-fever investigations, evidence was secured by this laboratory in Montana, Idaho and Wyoming, that indicated that the wood tick (Dermacentor anciersoni) is the most important single factor in the causation of human infection with tularaemia in the Rocky Mountain States. The investigations of tularaemia conducted at the Hygienic Laboratory are referred to on page 61. ADMINISTRATIVE HEALTH PRACTICE An office of administrative health practice was established during September, 1923, for the purpose of cooperating with the committee on administrative practice of the American Public Health Association in a resurvey of municipal health service in the larger cities in the United States. During the present year the resources of this office have been directed chiefly to the preparation, editing, and final review of a comprehensive report covering the principal health activities in the 100 largest cities which were surveyed by service officers during 1924. The publication of this report has been delayed • in order to allow the various authors sufficient time in which to complete their manuscripts and revise their data so that the individual chapters might present a coordinated review of present-day publichealth practice. At the close of the fiscal year the report is practically completed and ready for publication. As a result of contacts established during the recent survey, many requests were received from municipal health authorities and others for detailed information concerning current practice or special data in respect to certain activities. In attempting to supply this information from the material already collected, the inadequacy of detailed records of existing practice even in the well-defined fields of public-health activities was clearly emphasized. The absence of universal standards and clear-cut definitions and the continued application of many methods and procedures that are inconsistent with our present knowledge concerning the cause and prevention of disease constitute some of the obvious defects in the administrative programs now in force. Further progress in public-health work will depend largely upon the gradual development of new principles and the reconstruction of many of the standards or practices that are now generally accepted. It is reasonable to expect that further experience and trial will bring about continued improvement in the technique of administration and in the machinery and equipment needed to promote our public-health interests. PUBLIC HEALTH SERVICE 37 During the present fiscal year the office of administrative health practice was moved to new and more commodious quarters provided by the Johns Hopkins School of Hygiene and Public Health in Baltimore. Incidental to other work of this office, a survey of the health activities of Alexandria Va., was undertaken at the request of the municipal authorities, who were desirous of reorganizing the health department. CHILD HYGIENE Field investigations in child hygiene were carried on under the direction of Senior Surg. Taliaferro Clark until he was relieved from duty on January 20, 1926. His successor, Surg. Grover A. Kempf, assumed charge of the work on March 29, 1926. The investigations undertaken included research in special problems of child health and studies in child-health administration. MENTAL AND PHYSICAL STATUS OF NEGRO CHILDREN A request received by the service for information concerning negro children led to a realization of the fact that very little reliable data on this subject were available. As a means of supplying this definite need, the service undertook a study of the physical and mental status of negro children in the city of Atlanta, Ga. This work was carried on in cooperation with the Georgia State Board of Health and the Atlanta Board of Education. Beginning in September, 1925, and continuing throughout the school year, a large amount of data has been accumulated. Thirteen schools were visited and 5,168 children, between the ages of 6 and 14 years, were given physical examinations. In addition, careful measurements were taken and much valuable anthropometric data collected. In five of the Atlanta colored schools it was possible to conduct psychological examinations in addition to the physical examinations and measurements, and the results of 2,893 group tests and 606 individual tests were secured. In the group testing, the Otis advanced examination wat used for the fifth and sixth oracles, and the Otis primary examination for all grades below the fifth. In the individual examinations use was made of the Sanford-Binet test, supplemented when desirable by the Lincoln hollow square, Healy construction A, and Kohs's block design tests. The psychological material is already in process of analysis and a report on the subject will be made shortly. The physical and anthropometric data are so extensive that more time must elapse before the results of this part of the investigation can be adequately presented. COOPERATION WITH THE GIRL SCOUT ORGANIZATION On the request of the director of the Girl Scouts of the District of Columbia, the child hygiene office continued the physical examination of girls who registered for attendance at the Girl Scouts camp. At the close of the year 119 examinations had been made.. 38 PUBLIC HEALTH SERVICE GROWTH AND DEVELOPMENT OF SCHOOL CHILDREN The present fiscal year marked the completion of five years Of child hygiene investigations in Hagerstown, Md. This study of the physical status, growth, and development of a gradually widening group of elementary school children is assuming important pi-oportions. The year's work included studies in health supervision of school children over a protracted period, studies in oral hygiene, and studies in physical development. Physical examznations.—During the school year 3,625 children were given complete physical examination. Of this number, 2,851 were children who were first examined in 1921-1925. The physical examinations for this year revealed the fact that there was a slight increase of the total amount of visual defect among the older children, the new entrants having 25.58 per cent of more or less visual defect while the older group had 29.71 per cent. The same slight increase is seen in serious defects of vision, 9.17 per cent of the new entrants having serious defects as compared to 11.54 per cent in the older children. Of the total number of children examined, only 20, or 0.55 per cent, were found who had never been vaccinated, and 14 of those were new entrants. Oral hygiene.—An exam;nation of the mouth, with numeral rating, was given to each of the 3,625 children examined. Thefollowing defects with percentage of each in the number examined were noted: Per cent having defect Carious temporary teeth Carious permanent teeth Missing permanent teeth Gingivitis Fistulae (gingival) 72.06 72.66 12.33 12.41 5.82 It was found that the percentage of gingivitis among the new entrants was more than four times that among the older children, 62.01 per cent of the new entrants being affected and only 14.1 per cent of those who had had from one to four years of health supervision in the schools. • Physical development.—The study in physical development consisted of a series of measurements on a group of approximately 3,400 children. This was a continuation of the special study of physical development as expressed in increments of weight and height. Weights were taken at intervals of one month, one standing and two sitting heights (methods of Dreyer and Hrdlicka) at approximately six-month intervals. A total of,20,557 height measurements (standings and sitting) were secured during the school year. An investigation of the consistency of the two sitting heights (methods of Dreyer and Hrdlicka) was undertaken wth a selected group of 200 children. Trunk measurements of each child were taken ten times by each of the two methods. PUBLIC HEALTH SERVICE 39 Following are the percentages of variation for boys and girls per 1,000 measurements: Dreyer Girls Boys Total lirdlicka 17.2 14.8 5.5 7.2 32.0 12.7 A detailed report of this study will be made later. In addition to the above studies, a series of special chest measurements was made with a vernier caliper upon the entire group of children receiving physical examination. STUDIES IN NATURAL ILLUMINATION OF CLASSROOMS The studies in illumination were continued throughout the year, and consisted of (1) observations of natural illumination of classrooms in Washington, D. C., and (2) analysis of the data obtained through the illumination studies made in Hagerstown, Md., the preceding year. Hourly observations of natural illumination were made on selected desks in five school buildings in Washington D. C., one building being used on each school day of the week. Each hourly series of inside measurements was preceded and followed by an outside determination of the brightness of the sky and the measurements for the desks in each room were followed by a determination of the illumination at the windows and normal to the glass. The buildings selected for this study were among those in which the eyes of the pupils had been examined by the service investigators during the preceding school year. The purpose of the study has been twofold: (1) To determine any correlation which may exist between the relatively poor illumination observed for some of the buildings and the poor vision previously noted, and (2) to study the illumination obtained with the types of architecture and environment of the five buildings studied. Satisfactory progress was made in the analysis of the data obtained at Hagerstown, Md. The first report of this study was issued in January, 1926.4 This bulletin was written from the standpoint of the average school commissioner or county official and only general averages of the observations were given. Among the conclusions reached are the following:.. 1. The inside illumination, apparently, is influenced more by the sky brightness than by the outside illumination. 2. From the desks in the row farthest from the windows the illumination was below the accepted standard of 5 foot-candles much too frequently to be ignored. 3. Artificial lighting should be provided, at least for the half of the rooms farthest from the windows. The lighting circuit should .be divided so that only the dark half of the room may be lighted when necessary. 4. The width of the rooms for unilateral lighting should not be much in excess of 20 feet, at least in the locality studied. 4 Public Health Bulletin No. 159. 40 PUBLIC. HEALTH SERVICE 5. For a room about 20 feet wide the glass-area floor-area ratio should not be much less than 20 per cent. 6. The windows should extend as near to the ceiling as possible, assuming a ceiling height of 12 to 14 feet. 7. The windows should extend as near to the rear wall of the room as possible, especially on the west side of the building. 8. The "reduced square degree" is a better measure for the sky vault which may be visible at a desk than merely the square degree. 9. The rule that every desk should have visible at least 20 "reduced square degrees" of sky vault is apparently a very good one. 10. Near-by trees, particularly large, tall ones, reduce the visible sky vault so materially as to suggest, from the standpoint of lighting alone, that all trees should be eliminated from plats of ground used for school instruction or study purposes. However, in order to meet the demand for the beauty and shade provided by trees, it would seem advisable to recommend that trees should never be planted closer than 50 feet from the school building, and then only provided they are kept topped and trimmed, so that their maximum height shall not exceed half the distance to the building. 11. The distribution of light over the rooms is better on the side of the building opposite the sun than on the same side as the sun. A further careful scientific analysis of the data is being made and will be presented in a later report. It appears that the"inside-out-side"illumination ratio is• not constant as was believed by some investigators, but has at least three definite laws of change. When this analysis has been completed it is believed that it will prove to be fundamental for the future development of the subject. VISION OF SCHOOL CHILDREN The studies of the vision of school children, begun during the preceding year, were continued in cooperation with the departments of health and education of the District of Columbia. During the summer session in 1925 and the regular session of 1925-26, a total of 1,149 children were examined in 12 schools. Visual acuity was tested before and after the use of a cycloplegic, and refractive errors were carefully rated. The results of the examination after use of the cycloplegic are shown in the following table: Regular school Summer school Type Number Per cent Number Per cent Normal or emmetropic Hyperopic Myopic Simple hyperopic astigmatism Simple myopic astigmatism Compound hyperopic astigmatism Compound myopic astigmatism Mixed astigmatism Total 37 693 47 22 5 171 8 19 1,002 3.69 69. 1 4.68 2.19 .49 17.00 .79 1.89 1 106 8 2 1 24 0 5 0.6872.Oa 5.4 1.3 .68. 16.3 0 3.4 147 There is a marked difference in the percentage of normal vision found before and after the use of a cycloplegic. 41 PUBLIC HEALTH SERVICE Regular Summer school school Per cent Per cent 60.54 63.47 3.69 .68 Before cycloplegic After cycloplegic Many children with 20/20 visual acuity before the use of the cycloplegic have only 20/200 or 20/100 after its use. The ultimate result of such cases of eye strain is an important problem. It is interesting to note that the percentage of mixed astigmatism in the summer school is decidedly greater than that in the regular school-3.4 per cent in the former and 1.89 in the latter. On the other hand, the percentage of normal vision is decidedly less in the summer school. Since the summer school is attended largely by retarded children, it is possible that there may be a definite relation between their retardation and poorer eyesight. DENTAL HYGIENE IN SCHOOL CHILDREN The health officer of a county in the State of New Mexico was of the opinion that the children of Spanish extraction of his county had better teeth than the children of other sections of the United States. A medical officer was assigned to this county to make a special investigation to determine whether or not these children had better teeth and also, if possible, why. A group of approximately 500 urban children and the same number of rural children were given a physical examination, particular attention being paid to the teeth. With the exception of the dental condition, the general physical condition was inferior to the children examined in other parts of the country. Taking the first permanent molar as an indicator, the children of this county were found to have better teeth than tlm children formerly examined in New York, Delaware, Virginia, West Virginia, and Florida. Defective or missing 6-year molars 1 or more 2 or more Age All ages Under 8 9 to 12 13 and over East West East West Per cent 50 29 53 53 Per cent 13 3 12 28 Per cent 33 18 38 37 Per cent 8 3 8 13 The use of the toothbrush is practically unknown in the rural sections of the county. There is no dental hygiene practiced, and only six children had ever visited a dentist. The diet is simple and natural and undoubtedly has an important bearing on dental conditions. 42 PUBLIC HEALTH SERVICE INDUSTRIAL HYGIENE AND SANITATION The activities of the office of industrial hygiene and sanitation were carried on under the direction of Surg. L. R. Thompson. They included (1) investigations of tetraethyl lead; (2) studies of occupational health hazards; (3) studies of occupational diseases; (4) studies of the causes of industrial absenteeism; (5) statistical studies; (6) cooperation with Government departments; (7) cooperation with industrial and other agencies. INVESTIGATIONS OF TETRAETHYL LEAD The field studies of tetraethyl lead have been conducted under the direction of Surg. J. P. Leake. The committee, consisting of Dr. W. H. Howell, chairman, Dr. A. J. Chesley, Dr. David L. Edsall, Dr. Reid Hunt, Dr. W. S. Leathers, Dr. Julius Stieglitz, and Dr. C.-E. A. Winslow, which was appointed by the Surgeon General to determine "the health hazards involved in the retail distribution and use of tetraethyl lead gasoline motor fuel," presented a report on January 17, 1926, before a public conference. The report of the committee was based upon the study made by Doctor Leake, assisted by a number of the staff of the Hygienic Laboratory and of the section of industrial hygiene and sanitation. Two hundred and fifty-two individuals were studied, all adult males. They were divided into five groups: Group A (negativecontrol group)—drivers of automobiles in which the gasoline used contained no lead; Group B (test group)—duties similar to those of Group A, drivers of automobiles using ethyl gasoline which contained lead; Group C (negative-control group)—representing garage workers, gasoline fillers, etc., working in garages and service stations where the gasoline did not contain lead; Group D (test group)— similar. to Group C, except that ethyl gasoline was handled in the garages or stations; Group E (positive-control group)—employees in industrial plants in which there was a serious exposure to lead other than tetraethyl lead. Each individual was subjected to a careful clinical examination, and in addition, smears were made from his blood and a specimen of feces was collected. The blood smears were examined for stippling of the red cells, and the feces for the presence of lead, methods of great accuracy, which were especially devised for this study, being used. The results of these studies brought out the following facts: The results in Groups A and B were practically identical. Lead was found in the stools of members of both groups; and in this connection, 20 examinations which were made in Washington, of 10 workers in the Hygienic Laboratory who had no known exposure to lead, also showed small quantities of lead ranging from 0.047 milligram to 0.29 milligram per gram of ash of feces. Group C, representing garage workers and handlers of gasoline with no lead, showed an indication of slightly greater excretion of lead. Group D, similar to Group C, but using ethyl gasoline, showed still further increase of the amount of lea excreted. The committee believed that at least part of this increase might have been due to the use of ethyl gasoline. Group E, which was known to be exposed to a definite lead PTJBLIC HEALTH SERVICE I( 43 hazard, showed that over 80 per cent had more than 0.3 milligram of lead for each gram of ash of feces, and in some cases the lead was present in concentrations as great as 3 milligrams per gram of ash. The study of the stippled cells found in the blood of the workers in these various groups gave a picture similar to that of the excretion s of lead in the feces. The committee concluded— (1) That drivers of cars using ethyl gasoline as fuel in which the concentration of tetraethyl lead was not greater than 1 part to 1,300 parts per volume of gasoline showed no definite signs of lead absorption after exposure of approximately two years. (2) That employees of garages and service stations may show evidence of lead absorption and storage; and that in garages and service stations where ethyl gasoline is used the amount of apparent absorption and storage was increased, but that the effect was slight as compared with that in Group E, and that for the periods of exposure studied this was not sufficient to cause detectable symptoms of lead poisoning. An interesting and important fact brought out in this study was the finding of considerable amounts of lead (0.08 to 2.23 per cent) in the dust of garages whether the gasoline used contained lead or not. Carbon monoxide was also found in dangerous quantities in the air of the garages during those periods of time when the cars were being moved. As the result of the committee's recommendations, a series of regulations covering the control of the manufacture and blending of tetraethyl lead and ethyl fluid, the mixing of ethyl fluid and gasoline, and the distribution and sale of ethyl gasoline was prepared by the Public Health Service and submitted to the various State health officers for their criticism and recommendations with a view to assisting the States in obtaining uniform regulations. These suggested regulations regarding the manufacture, blending, and mixing of tetraethyl lead and ethyl fluid are being followed by the manufacturers and distributers. SURVEYS OF OCCUPATIONAL HEALTH HAZARDS • Ventilation studies.—These studies have been continued under the supervision of Associate Sanitary Engineer Leonard Greenburg. Laboratory studies have progressed in determining the electrical charges and buffering capacity of various industrial dusts, with the idea that a knowledge of these properties of dust may give a better understanding of the mechanism by which dusts may cause injuries to lung tissue. As a result of a paper presented before the American Public Health Association on the subject of window and fan ventilation, a study of schoolroom ventilation has been undertaken at Rochester, N. Y., by the committee on heating and ventilation of the American Public Health Association in cooperation with the United States Public Health Service. To a certain extent the principles evolved for this study should be applicable to factory ventilation. . In cooperation with the National Safety Council studies regarding the use of certain solvents in industry have been carried on over the 44 PUBLIC HEALTH SERVICE past two years. These studies have disclosed the facts that the use of benzol is associated with a specific type of anemia; that there exists considerably more of this type of poisoning than has hitherto been known to exist; and that benzol poisoning presents a very specific type of blood picture which now readily leads to the identification of poisoning in association with a definite occupational exposure to benzol. The survey brought out evidence that in the atmospheres of American industrial plants with excellent systems of exhaust ventilation there could still remain a quantity of benzol vapor equal to, about 100 parts per 1,000,000 of air, and that in this proportion benzol vapoF in air is capable of producing industrial poisoning.. At the other extreme it was found that in plants without any kind of ventilation whatsoever the quantity of benzol vapor could exceed 4,000 parts per 1,000,000 of air. In connection with the use of certain solvents in• industry, the Service has also been cooperating with the National Safety Council in the study of spray painting, and with the Department of Labor and Industry of the State of Pennsylvania in the formulation of regulations for the control of spray painting in that State. Dust studies.—Under the direction of Asst. Surg. A. E. Russell, the series of dust studies which have been carried on by the Service for the past three years has been continued. The surveys relating to cement dust, granite dust, hard-coal dust, and silver polishing have been completed. There still remain three groups under observation in connection with the studies—soft coal, vegetable, and municipal dusts. The study of silica dust includes the observation on approximately 1,000 workers in 14 granite manufacturing plants. Physical examinations have been made of 520 of these workers, with X-ray examinations of approximately 200. Of special interest is the fact that six autopsies have been obtained, four of which have shown pneumonoconiosis complicated with tuberculosis, while one showed an early case and one a moderately developed case of pneumonoconiosis. These autopsies have all been studied by Consultant Leroy Gardiner and should give a good presentation of the pathology of pneumonoconiosis alone and complicated with tuberculosis. Among the employees studied there have been 22 deaths from pneumonoconiosis complicated with tuberculosis, and ,there are at present 20 ill with this disease. The hard-coal-dust study covers a group of 740 miners. About 70 X-rays and 425 physical examinations have been made of these cases. In addition, about 30 men who have retired from the mines because of ill health have been examined. A canvass of the miners' families was also made with a view to determining the sanitary conditions of their homes and the amount of respiratory diseases prevalent among the members of the family, particularly with reference to tuberculosis and asthma. The study of physical and chemical characteristics of the dusts has been made by Asst. Physical Chemist J. J. Bloomfield, under the direction of the medical officer in charge. In the granite industry a total of 220 dust observations were made in 14 sheds, divided so that an equal number was made in the summer and winter seasons. As the result of these observations it was found that approximately 94 PUBLIC HEALTH SERVICE 45 per cent of the men in the group investigated were exposed to an amount of dust from 6 to 600 per cent in excess of the standard advocated by the South African investigators. In a general way the death rate from tuberculosis in the various occupational groups in the granite industry varied directly as the exposure to the amount of ,dust increased, as determined by the number of particles per cubic foot of air. Forty observations were made as to the atmospheric dustiness in koft-coal mines. This preliminary report showed that of the 210 men under observation about 49 per cent were exposed to exceedingly large quantities of dust, of over 60,000,000 particles per cubic foot ,of air. This count reached as high as 257,000,000 particles per cubic foot among the occupational group classed as coal cutters. In the preliminary observations of vegetable dust made at Greenville, S. C., in addition to observations on the amounts and character .of the dust, daily records are being kept as to the wet and dry bulb temperature and kata thermometer readings. The cement-dust study, which is ready for publication, brings out several very interesting observations. Among the employees working in this dust the highest respiratory incidence rate occurred among those who quit the industry and did not return. The next highest was among those who quit and came back, while the lowest respiratory rate was recorded for those who did not quit. The respiratory rate for these employees was much above the rate for any other industry studied in which dust was not a hazard. Studies in illumination.—Undier the direction of Physicist James E. Ives, studies of the effect of illumination on eyesight and production have been continued. The most important of these observations have been carried on at the Chicago post office, where approximately SO letter separators have been under observation for the past two years, working under degrees of illumination which have been varied from approximately 2 to 25 foot-candles. In this study an attempt has been made not only to determine the effect of illumination on production but also to discover whether changes in illumination have any effect on speed of vision, acuity of vision, and fatigue of the eye. An attempt has been made to express mathematically the rate of increase in production under low degrees of illumination, from 0 to 3 foot-candles. The readings of daylight taken by the Case photoelectric cell have now been completed for a period of over one year and are being compiled as representative of the actual amount of daylight for this latitude in the United States and to be used for study as to the relationship between daylight andhealth. In addition,observations have been made as to the best method of measuring an recording ultra-violet radiation, with the idea of determining the actual ratio between ultraviolet radiation and daylight. STUDIES OF OCCUPATIONAL DISEASES Posture in industry.—As the result of the preliminary analysis of the data obtained on posture it was thought that muscular tone might be a considerable factor in determining posture. To test out this idea two similar groups of high-school boys at the George Washington 46 PUBLIC HEALTH SERVICE High School, New York City, were employed; one group was given special physical training to increase muscular tone, while the second was excused from all gymnasium work and was requested to take as little exercise as possible during the period of observation. Complete physical examinations were made at the beginning and end of the study and photographs were made at the same time. Additional measurements were also made, including strength tests of push, pull, and lift; lung capacity and lung fatigue; and measurements of the lumbar and cervical curves of the spine. As would be expected, the boys taking physical exercise showed a general improvement in their. physical condition over the control group. Whether or not any change in posture took place as the result of these exercises has not yet been determined. These studies were made under the supervision of Surg. Louis Schwartz. Occupational dermatosis.—A tentative plan for the study of occupational dermatosis during the coming year has been made, and a list of all known cases has been compiled for early publication in Public Health Reports. STUDIES OF CAUSES OF INDUSTRIAL ABSENTEEISM The investigations of industrial morbidity have been continued in cooperation with the office of statistical investigations under the supervision of Statistical Expert Dean K. Brundage. The data for study and analysis have been obtained from three different sources: (a) Records of 35 sick-benefit associations with a combined membership of approximately 135,000 industrial employees. (b) Records of medical departments of several large industrial establishments. (c) Records collected by the office of industrial hygiene and sanitation in connection with specific studies. The analysis of the data collected has enabled us to have a better understanding of the average frequency of attacks of disabling sickness and the average duration of such attacks at different ages among males and females, the effect upon the sickness rate of specific physical defects, racial susceptibility or predisposition to certain diseases, and the influence of marital status. The amount of disabling sickness in excess of the expected rate after adjustment of the influence of the more important factors, except occupation, affords, it is believed, a fairly satisfactory measurement of the effect of occupation or the specific industrial-health hazard under investigation. Another matter of special interest to industry has been the development of a scientific method for evaluating the effect of industrial medical services upon the frequency and duration of sickness of industrial employees having access to such services. The five-year study of disability among 133,000 industrial employees absent on account of sickness for eight consecutive days or longer has indicated the importance of the respiratory group of diseases in causing loss of time from work. Influenza and grippe accounted for 18 per cent of all sickness claims, and from the standpoint of interrupted production and wages lost no other disease has been so important in recent years. In the five years ending December 31, 1924, influenza and grippe disabled industrial employees at a rate which was six and six-tenths times the frequency of the epi- PUBLIC HEALTH SERVICE 47 demic, endemic, and infectious diseases against which public-health work is so largely directed. Although pneumonia (all forms) occurred at only one-sixth of the rate of influenza, it appears to constitute a problem of some seriousness in the iron and steel industry, where the frequency of pneumonia was practically twice as great as in the other industries from which reports were received. Sickness rates, even when three-year averages have been used, show a wide variation according to industrial establishments. Of the plants reporting to the Public Health Service,the plant with the highest sickness rate had nearly 350 per cent more sickness than the plant which recorded the lowest rate. The reasons for this tremendously wide difference are, of course, of vital importance to industry, and from our analysis part of the explanation would appear to lie in the type of the individual, from a physical standpoint, who is attracted to the industry or establishment by the nature of the work. In many industries and in different factories in the same industry a selective process of this sort seems to be continually going on. It must have an important effect on the sickness rates for the industries. STATISTICAL STUDIES The preparation and analysis of industrial hygiene .problems re corded elsewhere have been carried on in cooperation with the statis. tical office under the direction of Associate Statistician Rollo H. Britten. A study of the physical condition of 10,000 male industrial workers, referred to in the last annual report, was published during the year.5 The most important study of the year has been the analysis of the posture data collected by Surg. Louis Schwartz. This survey includes 2,200 boys and men from 3 to 60 years of age. The primary point of the investigation, as set forth in the last annual report, was to determine whether there is a standard posture, deviations from which in industry could be regarded as showing the effect of occupation. The preliminary analysis of these data seems to indicate that it is impossible to describe any standard posture which is possible of attainment for all types of individuals. The basis for this statement will be the topic for a final paper in connection with the analysis of the posture data. It is expected to prepare a series of papers on the following points related to body development: (a) The factor of build in physical examinations. A satisfactory classification of build involves not only height and weight but also the amount of fat or stockiness. (b) Body growth with age, with consideration of adequate physical measurements of males of all ages, relating to height, weight, chest diameters, chest circumference, abdominal circumference, etc. (c) Studies of measurement of physical fitness among males. In addition to the physical measurements the examination includes determination of the vital capacity, blood pressure, pulse rate, chest expansion, lung fatigue, etc. (d) A study of the relationship of various parts of the body to other parts, as, for example, the lumbar spinal curve to abdominal protrusion, etc. 5 Public Health Bulletin No. 162. 48 PUBLIC HEALTH SERVICE • (e) Strength tests and growth. Relationship between the strength tests which were used in the study and health, physical fitness, and body measurements. (f) Pubescence in relation to build and body measurements. (g) Flat-footedness among men and boys. (h) Age curves of the defects and diseases among men and boys. (i) Lateral deviations of the spine among males, which, in addition to the character and extent of the lateral deviation, may be correlated with right and left handedness and weight bearing on the right or left foot. COOPERATION WITH OTHER GOVERNMENT DEPARTMENTS Post Office Department.—Cooperation has been continued with the Post Office Department in a further test to determine the most efficient system of lighting in post offices. Bureau of Standards.—The study of occupational hazards among the employees of the Bureau of Standards was continued. Bureau of Mines.—Studies of mine sanitation were carried on during the fiscal year 1925-26 with the Bureau of Mines, Department of Commerce, the medical personnel being detailed from the Public Health Service to that bureau for the purpose. Surg. R. R. Sayers was in charge as chief surgeon of the Bureau of Mines. The investigation of the physiological effects of abnormal atmosspheric conditions was continued by the Bureau of Mines in cooperation with the American Society of Heating and Ventilating Engineers. Some of the results of investigations conducted in atmospheres of low temperatures with still and with moving air were published by Dr. W. J. McConnell and C. P. Yagloglou in the Journal of the American Society of Heating and Ventilating Engineers, for May, 1926, under the title "Work tests conducted in atmospheres of low temperatures and various humidities in still and moving air." A summary of the low-temperature study was prepared by Surgeon Sayers for the International Critical Tables for 1926: At rest in still air with a temperature of 65° to 70° and with 100 per cent relative humidity, subjects stripped to the waist felt slightly cool or comfortable; under these same conditions with moderately hard work they felt comfortable. At rest in still air with temperatures from 55° to 60°, 100 per cent relative humidity, clothing was required for comfort, while at moderately hard work under these condition g the subjects were comfortable to cool stripped to the waist, and at 45° to 50° subjects working moderately hard felt cool stripped to the waist. Another paper on this subject was published in the Journal of the American Society of HeatiAg and Ventilating Engineers, for June, 1926, by F. C. Houghten, W. W. Teague, and W. E. Miller, under the title, "Effective Temperature for Persons Lightly Clothed and Working in Still Air." A general summary of the literature on the physiological effects of abnormal temperatures and humidities has been completed by Doctor Sayers. Sanitary surveys of mining camps have been conducted during the year, and in April, 1926, a report was made on the sanitary conditions of mining camps in the State of Alabama.6 6 Reports of Investigations, Serial No, 2746, Bureau of Mines. PUBLIC HEALTH SERVICE 49 As referred to in the last annual report, the study of lead poisoning (mining lead carbonate) in the mines of Utah was completed and will appear as Bureau of Mines Technical Paper No. 389. This report revealed the fact that lead poisoning is more commonly contracted in the mining of lead ores than has been thought. The study of the causes of death among miners has been carried on for several years, and so far the data have been collected from • the States of Nevada, California, Arizona, Colorado, and Wyoming. The study'is partially complete for Alabama and Utah. This study has been made for the purpose of ascertaining the diseases and types of accidents most prevalent among miners. As representative of the United States Public Health Service and the Bureau of Mines, Doctor Sayers participated in the International Conference on Oil Pollution of Navigable Rivers. Certain general restrictions regarding the discharge of oil into navigable waters were agreed upon by the conference. Other studies carried on by the Bureau of Mines included physical examination and X-ray studies of miners; the completion of the experimental work done in connection with the study of health hazards from the use of tetraethyl lead; synthetic atmospheres in operations, the results of which were published by Doctor caisson operations of Helium-Oxygen Atmosphere in Diving Sayers in "The and Caisson Operations" in Anesthesia and Analgesia, the publication of the International Anesthesia Research Society for June, 1926. A report entitled ",Stream Pollution by Wastes from By-Product Coke Ovens" was published during the year.7 Only part of the work outlined in this study has been completed. The work will be continued during the present year. COOPERATION WITH INDUSTRIAL AND OTHER AGENCIES After two years of effort an agreement has finally been reached as to the standard technique of prone-pressure method of resuscitation. The exact wording of the technique of the method will appear the same in all publications put out by the United States Public Health Service,the United States Army,the United States Navy,the American Red Cross, the Bureau of Mines, the Association of the Industrial Physicians and Surgeons, the National Safety Council, and certain other industrial associations and universities. The effect of•such standardization in the technique of the prone-pressure method of resuscitation should be far-reaching and beneficial, especially in those industries where gas poisoning, electrical shock, or the danger of drowning forms an important problem. MENTAL HEALTH During the fiscal year 1925-26 the office of field investigations of mental health was occupied in gathering data relative to an epidemiological study of mental diseases occurring during the calendar years 1920 and 1925 in the city of Boston. This work was begun in the fall of the preceding year. 7 Reprint No. 1042 from the Public Health Reports, Sept. 26, 1925. • 50 PUBLIC HEALTH SERVICE The purpose of this study is to throw light, if possible, upon the reasons for the high proportion of foreign-born persons admitted to our public institutions for the insane and to ascertain whether or not this preponderance is due to the actual existence of a greater amount of insanity among foreign-born peoples or to a differences in the utilization of public institutions by foreign-born and nativeborn persons. It may be that the foreign born are more prone to accept the services of public institutions without utilizing community sources of advice and treatment, while the native born exhaust the facilities of the community before resorting to such institutions. It is evident that if such a situation exists it may well account for the presence of a larger number of foreign than native-born persons in State institutions. This is an exceedingly important question from the standpoint of immigration and the effectiveness of our immigration laws and will eventually be the means of contributing some important results to the understanding of mental diseases among our foreign-born population. It is also hoped that this study will contribute to a better understanding of the conditions under which mental disorders occur in urban populations and of the factors which are instrumental in causing persons to seek relief from the public treasury. During the course of this study visits were made to the various public and private hospitals for the insane in Massachusetts and records of individual cases that had been admitted from the city of Boston were read and abstracted. Upon the completion of the 1920 cases similar work was inaugurated with regard to Boston cases admitted to State institutions during the calendar year 1925. The collection of data for this investigatfon, which includes approximately 3,500 cases, has now been completed and the material assembled for correlation and analysis. In addition, this office has been concerned in establishing a literature index in which books and pamphlets bearing upon mental hygiene, psychology, neurology, psychiatry, and allied subjects are being assembled and catalogued. A complete bibliography of this literatura will be of considerable practical value for future studies in mental hygiene. MILK During the fiscal year ended June 30, 1926, the milk investigations of the Public Health Service were continued under the direction of Sanitary Engineer Leslie C. Frank, with headquarters at Montgomery, Ala. An investigation of the possibility of unifying milk-control work in the United States.—During the year two additional States adopted the standard milk-control program recommended by the United States Public Health Service. Ten States are now operating under the program. By the end of the fiscal year 1924 seven cities had passed the standard milk-control ordinance. By the end of the fiscal year 1925 the number of cif_ es having passed the ordinance had increased to 53. At the present time the number of cities having adopted the standard ordinance is 100. PUBLIC HEALTH SERVICE 51 Annual surveys of the milk sanitation status of cities.—The work of determining the milk sanitation status of cities was continued during the year, ratings being determined for 102 cities. The data resulting from the surveys were transmitted to the various cities through the State boards of health for their information and use. This service is intended to keep each city informed of the progress it is making in milk control and how the results attained compare with the results attained in other cities. Studies of the prevalence of milk-borne outbreaks of disease.— During the year the studies of the prevalence of milk-borne outbreaks of disease were continued. Research work on pasteurization niachinery begun.—During the year testing work in connection with pasteurization machinery was begun at Chicago, Ill. The testing program includes the testing of all makes and types of pasteurization machinery in order to determine the thermal and time characteristics thereof. Evidence thus far secured indicates that certain of the designs of pasteurization machinery now on the market can not be depended upon to pasteurize milk properly, and the principal purpose of the work now in progress is to enable health officers to differentiate between properly designed and improperly designed machinery and also to know the conditions under which each type of machine must be operated in order to insure good results. STATISTICAL OFFICE The office of statistical investigations has been under the general direction of Statistician Edgar Sydenstricker. The investigations include work carried on in the statistical office independently as well as in collaboration with other stations of the division of scientific research and with other divisions of the service. The organization of the office of statistical investigations is as follows: 1. A tabulating and computing unit composed of the supervising statistical clerk, several trained statistical clerks, and a number of operatives for computing, calculating, assorting, counting, and tabulating machines. 2. A small statistical staff composed of persons trained in statistical methods and in public health. These were engaged in certain statistical and epidemiological studies and in rendering assistance of ,a technical nature to other offices in the division of scientific research and other divisions of the service. Collaborating closely with them are the statisticians in other offices and divisions of the service. 3. An advisory staff consisting of several consultants in statistics who were called upon for advice from time to time and for special •work. About two-thirds of the time of the statistician in charge was devoted to general statistical work outside of the office of statistical investigations. Approximately 50 per cent of the time of the remainder of the personnel of the office was devoted to assisting In the statistical work of other offices and divisions of the service. The statistical personnel of certain other offices in the scientific research division, such as industrial hygiene, child hygiene, nutri- 52 PUBLIC HEALTH SERVICE tion, influenza, and respiratory diseases functioned as a unit with the personnel of the statistical office, the personnel being used interchangeably on any occasion when it was deemed advisable. STUDIES IN MORBIDITY STATISTICS One of the principal pieces of work undertaken since the organization of the statistical office in 1920 has been the collection, by original field investigations as well as by cooperative effort with other agencies, of records of morbidity. It has been the aim to obtain information from all possible sources on the incidence and prevalence. of sickness resulting from specific diseases among population groups of different sexes, ages, occupations, economic, and social conditions, etc. During this six-year period a large amount of material has been obtained, constituting probably the largest collection of morbidity data in the United States and, of its kind, in the world. Some of the, results have been published in fragmentary reports from time to time,. covering special population groups. Thus, in collaboration with the office of child hygiene certain morbidity studies of school children have been published, and in collaboration with the office of industrial hygiene and sanitation a number of reports on sickness among industrial workers have been published. These cover only persons of certain ages and living under certain conditions and do not afford an adequate picture of the incidence or prevalence of sickness in the general population. Accordingly an experiment was begun in 1921 of keeping under continuous observation a sufficiently large general population group, composed of persons of all ages, sexes, different economic and social conditions, etc. This study was made in Hagerstown, Md., and was continued beyond the original time set for a total period of 28 months. Using the Hagerstown study of a general population group as a basis, the work was commenced, during the past year, of putting together the results of all of these morbidity records as well as records of physical examinations of thousands of children and adults into a preliminary report which, it is hoped, will give a more nearly complete picture of the evidences of ill health among persons of different ages and sexes, as well as of the age incidence of the principal diseases and conditions, than has been possible heretofore. It is hoped that this report will be ready for presentation within the next year. In the meantime, however, special reports of morbidity incidence and prevalence from various causes have continued to be presented currently. The series of reports on the "Frequency of Disabling Illness Among Industrial Workers," prepared under the supervision of Statistical Expert Brundage, has been continued. The results of the Hagerstown morbidity study are being issued in a series of papers under the general subtitle "Hagerstown Morbidity Studies,' three such papers having been completed. One of these was a report giving the general results of the study the se2ond was a brief paper. dealing with certain factors affecting the notification of communicable diseases, such as the extent to which cases of certain diseases' actually come to the notice of physicians, the extent to which physicians report the cases they attend, and the accuracy of incidence, rates based upon reported cases; the third was a report on the extent to which illness from different causes receives medical, hospital, PUBLIC HEALTH SERVICE 53 and home nursing care as well as service rendered by osteopaths, chiropractors, etc., in a typical small city. Other reports are in preparation. In addition to the foregoing a field study of morbidity was begun among about 1,000 employees of a large silk manufacturing establishment in Connecticut. This establishment had been cooperating with the Public Health Service for more than two years in furnishing records of absence on account of sickness to the statistical office for tabulation and analysis. The experience of two years suggested that there were possibly significant differences in the sickness rate for respiratory diseases among certain occupations, and one of the purposes of the present study is to obtain more information on the reasons for this difference. Accordingly, records are being obtained not only of the causes of sickness which entail absence from work but also of all attacks of illness particularly of respiratory ailments, with notations in each instance as to the clinical manifestations of each respiratory attack. In addition, records are being kept of the meteorological conditions in the locality as well as of the temperature and humidity conditions in the places of work and in certain rooms, the temperature and humidity conditions being controlled in certain rooms for the purpose of comparison. This inquiry is thus not only a general morbidity study but also work undertaken in conjunction with the offices of respiratory diseases and of industrial hygiene. In collaboration with the office of industrial hygiene and sanitation, current and other statistics of industrial morbidity are being analyzed under the supervision of Statistical Expert Brundage. In connection with the work on morbidity, a number of requests for advice and assistance from State and city health departments have been received which related to procedure in the notification of diseases and the analysis of case reports for administrative 'Ind epidemiological purposes. a STATISTICAL AND EPIDEMIOLOGICAL STUDIES OF SPECIFIC DISEASES The completion of the statistical study of scarlet fever, which was begun during the preceding year by Assistant Statistician Dorothy G.Wiehl, was delayed on account of the pressure of other work, but it will be submitted for publication during the early part of the coming fiscal year. In response to certain requests, the statistics of morbidity and mortality from diphtheria and measles were analyzed from the point of view of age, seasonal, and periodic incidence. In the instance of measles an analysis was made to supply certain information as to the probable rise and decline of its prevalence in view of the growing interest in efforts to reduce the incidence and sequelae of the disease among young children. In the case of diphtheria the purpose of the analysis was to determine as nearly as possible the probability of a rise in diphtheria prevalence within the next few years, the age incidence of the disease in the past in epidemic and nonepidemic periods and its fatality, especially in view of the desirability of measuring the effect of diphtheria immunization in the future. The completion of the study of mortality from tuberculosis, upon which considerable work has been expended during the past two years, was also delayed on account of work of more pressing im- 54 PUBLIC HEALTH SERVICE portance, but the statistical part of the work is practically completed, and the results will be presented as soon as possible. During the past year the studies on tuberculosis were carried on by Assistant Statistician Mary Gover, particular emphasis being given to an inquiry into the correlation between indices of certain constitutional factors in the population of various cities such as race, type of build, and death rate from organic diseases, and the general character of the; predominant occupations, and the death rate from pulmonary tuberculosis. This study has shown that, while the death rate from pulmonary'tuberculosis is correlated positively with the size of the negro population and negatively with the proportion of the population which are of recent immigration, it is also correlated negatively with certain evidences of constitutional type such as are afforded by certain physical measurements and by the incidence of organic diseases.. These correlations appear even when the effect of other factors are. held constant. The statistical study of tonsillitis, which was begun last year by Associate Statistician Collins, is now practically completed and will be submitted for publication shortly. The main indications of this study are that there is a very definite curve of age incidence of tonsil enlargements, defects, and attacks of tonsillitis, which is quite distinct from that of other respiratory diseases; that while the incidence of tonsillitis follows in general the same seasonal variation as that of respiratory diseases it manifests itself at times in unusual outbreaks apparently independent of other diseases; that there is a very definite correlation between the incidence of diseased tonsils and of rheumatism and similar conditions among adults; that there issome correlation between susceptibility to respiratory attacks such as coryza and the conditions of the tonsils; that, on the average, diseased-tonsil conditions are not reflected in any considerable degree in malnutrition or marked underweight among children. The records of morbidity from respiratory diseases which have been accumulated from various original and other sources during' the past six years are being compiled into a general report on statistics of sickness from respiratory diseases. This work is being jointly done by both the statistician in charge and others of the statistical staff. In addition to the specific studies referred to above a number of shorter pieces of work were completed during the year. Among these may be mentioned the following: The preparation of monthly papers on the world prevalence of disease, summarizing the current issues of the Epidemiological Report of the Health Section of the League of Nations. These papers have appeared regularly in the Public Health Reports since April, 1924. A brief study was made of the influenza epidemic during 1926, with especial reference to its chronology and geographic spread. It was shown that in the large cities of the United States, with a, total population of about 30,000,000, the 1926 epidemic was responsible for about 16,000 deaths in excess of what might have been expected had the normal death rate prevailed; that the epidemic followed a somewhat different geographical course from prior large epidemics, appearing first in Western States and traveling south, • PUBLIC HEALTH SERVICE 55 thence north and northeast, although evidences are also noted of its early appearance in Maryland and along the south Atlantic coast; that the mortality rate varied greatly in different localities both in the United States and in Europe; and that in the United States the mortality was confined chiefly to young children and persons past middle age. Attacks occurred at all ages without, however, the high incidence among adolescent and young adults which characterized the 1918 epidemic. WORK IN ASSOCIATION WITH OTHER OFFICES AND DIVISIONS OF THE SERVICE .A considerable part of the work of the office of statistical investigations was the rendering of assistance to other investigations in the division of scientific research and other divisions of the service. This cooperation comprised the following: (1) Technical advice and_ criticism on statistical procedure • (2) assignment of statistical personnel to assist other statistical units; (3) use of mechanical equipment and operators. The major part of this work has been with the following offices and divisions: 1. In the division of scientific research, with field investigations of child hygiene, of industrial hygiene and sanitation, of nutrition (on pellagra), diphtheria, interepidemic influenza and minor respiratory diseases, goiter, trachoma, and with the Hygienic Laboratory. 2. In the division of venereal diseases the statistical compilations of current reports on venereal diseases from State health departments and clinics have been carried on under the supervision of the office of statistical investigations. 3. The office of statistical investigations collaborated with the division of sanitary reports and statistics and the hospital division on a number of routine matters. The detailed reports on the statistical phases of the work of other units and divisions with which this office collaborated are included in their several reports. COOPERATION WITH OTHER AGENCIES In addition to answering routine requests for statistical information, cooperation with agencies outside the service during the past year has been principally as follows: With vital statisticians and epidemiologists in various States and cities on matters affecting statistical procedure, report forms for disease notification, planning of epidemiological studies, and the like. With committees and others on statistical questions of the American Public Health Association, American Statistical Association, the Service of Epidemiological Intelligence and Public Health Statistics of the Health Section of the League of Nations, the International Institute of Statistics. With the health demonstration personnel of the Milbank memorial fund, Statistician Sydenstricker having been detailed for part of his time as statistical consultant to that organization. 56 PUBLIC HEALTH SERVICE STREAM POLLUTION The studies of stream pollution which have been made during the past year have been carried out in pursuance of a general plan which has been followed continuously for a number of years, with substantially the same organization and for the most part the same personnel as in the preceding year. This work is under the direction of Surg. W. H. Frost, with Sanitary Engineer J. K. Hoskins in immediate charge of the laboratory at Cincinnati, Ohio, which is the base for laboratory research and for field parties sent out to other localities. A group of consultants consisting of Dr. Stephen A. Forbes, of the Illinois State Water Survey; Dr. Edwin 0. Jordan, of the University of Chicago; Mr. Langdon Pearse, sanitary engineer of the Sanitary District of Chicago; Mr. Earle B. Phelps, of Columbia University; and Dr. Lowell J. Reed, of Johns Hopkins University, keeps in close touch with the work, giving advice in the shaping of plans. Individuals of this group have also given material assistance in matters of technical detail in their respective fields. The principal activities during the past year have been— (a) Field studies of the conditions of pollution in certain waterways, selected for study because of some special consideration. (b) Laboratory research designed to throw more light on the biology of wastes and purification. (c) Studies, both collective and experimental, of the actual potential efficiency of modern water purification plants using rapid sand filtration and chlorination. (d) Miscellaneous activities, chiefly in the way of cooperation with other agencies engaged in studies of stream pollution and allied .subjects. FIELD STUDIES • (1) At the request of the State health authorities of Illinois and Indiana and the municipal authorities of Chicago, a study of the sewage pollution of Lake Michigan in the vicinity of the IndianaIllinois State line was begun in September, 1924, under the immediate direction of Sanitary Engineer H. R. Crohurst and Passed Asst. Surg. M. V. Veldee, with the active collaboration of the State and municipal authorities, especially the Sanitary District of Chicago. The field work on this investigation was brought to a close in November, 1925, after having been continued through somewhat more than a year. During this time, except when interrupted by unfavorable weather conditions, samples were collected at short intervals from a large number of sampling stations established in this area of the lake and were examined bacteriologically in a temporary laboratory established in Chicago for the purpose. At the saline time a comprehensive sanitary survey was made to locate and appraise sources of pollution. The lake area studied is of especial sanitary importance because it is the source from which cities in both States draw their water supplies, and because the safety of these supplies is seriously menaced by the increased pollution which has followed the great industrial development on the lake shore. It was the purpose of this study to PUBLIC HEALTH SERVICE 57 determine more precisely and in more detail than heretofore the distribution of sewage pollution in this area of the lake, its relation to particular sources, and, to some extent, its relation to changes in weather conditions, especially to the direction and velocity of the prevailing winds. It is believed that this purpose has been accomplished, and a comprehensive report, presenting the results of the study, including records of the quality of the municipal supplies, and leading to recommendations for remedial measures,.has been drawn up and forwarded to the State and municipal authorities directly concerned. It is not proposed to publish the report, since its interest and importance are local rather than general. (2) Early in the year requests were received from the State health authorities of Minnesota and Wisconsin for cooperation with them in a study of the pollution of the upper Mississippi River. A preliminary survey and conferences showed that an intensive study of conditions in the upper Mississippi, especially in the vicinity of Minneapolis and St. Paul, would not only be of value to the States and cities immediately concerned but might also be expected to yield information of more general significance in relation to certain basic problems of pollution and natural purification. Arrangements were accordingly made for undertaking a joint investigation, to be supported chiefly by the States and cities, under the direction of the service. Accordingly, Sanitary Engineer H. R. Crohurst was assigned in March, 1926, to take charge of this study, which has since been satisfactorily organized and is now well under way. The plans made contemplate continuance of field work, at least through the summer and autumn of 1926, and longer if practicable. EXPERIMENTAL STUDIES OF THE PHENOMENA OF NATURAL PURIFICATION Such careful and continued observations as have been made on the Potomac, the Ohio, and the Illinois Rivers have served to measure with fair precision the rates at which certain processes of natural purification proceed under the conditions obtaining in these streams during the period of study. A better understanding of these processes which will permit of making the best use of them in practice requires, however, that they be studied in more detail and under a wider range of variation in conditions affecting their rate. Accordingly, for several years past an important section of the work has consisted of the study of natural purification processes as exhibited in the laboratory under controlled conditions which may be varied at will. These studies have been conducted in the Cincinnati laboratory chiefly by Associate Chemist E. J. Theriault, studying in detail the nature and rate of chemical changes in polluted waters ;* Associate Bacteriologist C. T. Butterfield, studying the relations of certain groups of bacteria to these changes; and Special Expert (in limnology) W. C. Purdy, investigating the influence of plankton. To a considerable extent these three investigators have collaborated in experiments requiring technical knowledge of chemistry, bacteriology, and limnology. As a result of these studies important additions have been made to previous knowledge of the rate of oxidation of organic matter in water, which is of practical importance as establishing a better 14656-26 5 58 PUBLIC HEALTH SERVICE basis for estimating the oxidizing capacity of streams; and it has been shown that certain forms of plankton, through their effect on bacterial activity, exert an important influence on oxidation (see also Laboratory Bulletin 104,"investigations on Pollution and Sanitary Condition of the Potomac Watershed"). Two papers prepared by Mr. Theriault will be ready for publication in the near future, one reviewing comprehensively previous studies of biological oxidation, the 9ther presenting the results of further observations made recently at Cincinnati. At the present time experiments are being made with artificial channels so constructed as to reproduce on a small scale the physical conditions existing in natural streams. While researches of this kind, dealing with the biological theory of natural purification, may seem somewhat remote from the immediate administrative problems of stream pollution control, they have already found important practical applications in the improvement and simplification of methods for testing sewage, sewage effluents, and polluted streams, and in facilitating the calculations and forecasts requisite for planning comprehensive control measures. STUDIES OF THE EFFICIENCY OF WATER PURIFICATION Since 1924 systematic studies of the bacterial efficiency of waterpurification plants of the type most commonly used in this country, namely, rapid sand filters supplemented by chlorination have been in progress under the direction of Sanitary Engineer H. W. Streeter, with the constant advice of Mr. Joseph W. Ellms, special consultant in water purification. The purpose of the studies has been to determine more precisely the relation between bacterial content of the untreated water and that of the pffluent from the purification plant, to ascertain how this relation is affected by changes in the character of the raw water and in operation of the purification plant, and to study the practicability and cost of effective modifications in operation or design. The method pursued has been first to make a detailed study of the raw water, the design and operation of the plant, and the quality of the effluent at a number of municipal filtration plants selected as representative, and then to extend the observations by operations of an experimental filtration plant established at the Cincinnati laboratory. The collective study of municipal filtration plant, begun in the summer of 1923 and continued, as regards field work, until the autumn of 1924, has now been completed, and a report presenting and discussing the collected data is being prepared for publication.8 In addition to the completion of this report the work during the past year has consisted of observations on the experimental filtration plant, which has been in practically continuous operation. Two papers, one describing the plant and one giving a preliminary review of results, have been submitted for publication, and a more comprehensive report on the earlier series of experiments is well on the way to completion. The general plan and purpose of the studies and some of the results obtained have also been presented more or less informally at several meetings of technical organizations which 30, s A preliminary report on this study appeared in the Public Health Reports, Jan. • 1925. Reprint No. 987. PUBLIC HEALTH SERVICE 59 are specially interested in water purification. It is proposed to continue this work at least one more year, taking up in succession a series of experiments which are already pretty clearly defined. EPIDEMIOLOGICAL STUDY OF TYPHOID FEVER IN RELATION TO BACTERIAL QUALITY OF WATER SUPPLIES It is obviously desirable that studies of the bacterial efficiency of water purification and of the bacterial quality of municipal water supplies should be extended to include a study by epidemiological methods of the actual danger in terms of infection risk of water supplies of known bacteriological quality. It is especially important, in connection with the establishment of bacteriological standards for water supplies, to have more definite information as to the lower limits of bacteriologically demonstrated contamination which may be associated with epidemiological evidence of actual waterborne infection. The problem is of such complexity that any exact solution is probably impossible. It has, however, been evident for several years that certain cities situated on the Ohio River and taking their water supplies, from that stream offered unusually favorable opportunities for a study of this important question for the following reasons: Unusually exact records of daily examination of the water supplies of these cities are available currently and for several years past the raw water is so , dangerously polluted that even a brief accidental lapse in the efficiency of artificial purification is likely to result in water-borne infections with typhoid fever; the endemic prevalence of typhoid fever in these cities is low, so that even a small water-borne epidemic could probably be identified by careful epidemiological study; and even without intensive study the records of these cities in recent years show evidence which is at least suggestive of several minor water-borne epidemics. Accordingly, Past Asst. Surg. M. V. Veldee was detailed in March, 1926, to undertake an intensive study of the occurrence of typhoid fever in these cities in cooperation with the State and municipal health authorities. Unfortunately, a special exigency of the service made it necessary, before the end of the year, to assign Doctor Veldee to other duty, with consequent discontinuance of this study. It is proposed, however, to resume it within the next year. MISCELLANEOUS ACTIVITIES The compilation of the data collected in a field study and the preparation of a report properly presenting the results is usually an undertaking which is fully as laborious and time consuming as the original field work, and, as extensive field studies have been in progress continuously for a number of years, leaving a scant personnel available for the preparation of reports, a considerable accumulation of material had been carried over from previous years. Special attention has been devoted in the past year to completion of reports on such accumulated data. Two reports on the pollution and natural purification of the Illinois River have been completed— one a general report dealing principally with hydrometric, chemical, and bacteriological examinations, and the other presenting and discussing the results of a survey of the plankton. With the coraple- 60 PUBLIC HEALTH SERVICE tion of these and the other reports which have been mentioned practically no material remains for compilation except the data currently collected from studies now in progress, and the personnel are more free than for several years past to devote their full time to new work. From time to time during the year occasion has arisen for special work not included in the regular program of studies planned but closely related to either the current or the past work of the station. For the most part this extra work has been in the way of cooperation with other agencies engaged in work related to stream pollution. Thus, Sanitary Engineer J. K. Hoskins has been detailed for conference with the State water commission of Connecticut relative to inauguration of a program of stream-pollution control in that State, conference with certain officers of the service in regard to a study of the pollution of bathing beaches in the District of Columbia, and inspection of certain water supplies for the Veterans' Bureau. Sanitary Engineer H. W. Streeter has collected data on the status of pollution from by-product coke-oven wastes in the Ohio River, and prepared a detailed memorandum on the subject for the information and use of the Association of Health • Departments of Ohio River States. Associate Bacteriologist C. T. Butterfield was assigned for a short while to assist in organizing the laboratory established at Norfolk, Va., in connection with studies on the sanitary control of shellfish, and has served as one of the referees on bacteriological methods for the American Public Health Association committee on standard methods. Associate Chemist E. J. Theriault has visited Chicago for conference with technical experts of the Chicago Sanitary District relative to the technique and interpretation of biological oxygen demand determinations; and Special Expert W. C. Purdy has been detailed to California to assist State authorities in a study regarding the influence of certain plankton (algw) toward preventing the breeding of anopheline mosquitoes. The officers assigned to stream-pollution investigations have from time to time prepared a number of memoranda and letters giving more or less detailed technical information on stream pollution and related subjects. Also, during the year several organizations have, by permission of the Surgeon General, detailed members of their technical staffs to the Cincinnati laboratory to acquire familiarity with the technical methods used there. While such incidental duties have occupied, in the aggregate, a considerable proportion of the time of the station personnel, it is believed that the results achieved in promoting effective cooperation with other agencies have fully compensated for interruptions to the regular program of investigations. HYGIENIC LABORATORY Surg. G. W. McCoy was continued as Director of the Hygienic Laboratory and Surg. R. E. Dyer as Assistant Director. The chief of the section on infectious diseases, Surg. J. P. Leake, was relieved from the laboratory early in the fiscal year to take charge of the field investigations of the possible hazards associated with the use of tetraethyl lead in motor fuels. Several of the scientific workers have resigned and their places have not yet been filled, owing to the difficulty of obtaining successors at the salaries offered. PUBLIC HEALTH SERVICE 61 Three Hygienic Laboratory bulletins were issued during the year, and a considerable number of professional papers relating to work carried on in the laboratory were published by members of the staff in Public Health Reports and in other scientific journals from time to time throughout the year. At the end of the fiscal year the library of the laboratory contained a total of 12,176 bound volumes, of which 713 were accessioned during the year. The pamphlet collection received several hundred additions. The bibliographic reference work of the library has increased considerably during the past year, not only for members of the laboratory staff, but for the field service. A number of photostat copies of articles were prepared for the staff and field service. Work was continued on the arrangement, classification, listing, and storing of the duplicate collection of periodicals, serials, and State and municipal health publications. DIVISION OF PATHOLOGY AND BACTERIOLOGY The division of the work, routine as well as research, has continued under the followiner sections, as for several years past: Nutritional diseases, infectiousbdiseases, the biologics-control work, and pathological studies. STUDIES OF NUTRITIONAL DISEASES These researches were continued under the direction of Surg. Joseph Goldberger, assisted by Passed Asst. Surg. R. D. Lillie. Further work indicates that black tongue in the dog and pellagra in man are strikingly similar conditions as respects etiology. Work on white rats indicate that in these animals there may be induced a pellagra-like condition. A full report will be found under the report on field studies in nutrition. STUDIES OF INFECTIOUS DISEASES Tularaemia.—Researches by Surg. Edward Francis have established (1) the presence of the disease in Japan, and (2) the existence of the disease in eight States hitherto not included in its area of geographic distribution, which now comprises 24 States, the District of Columbia, and Japan. The occurrence in eastern Montana of a case of tularaemia in which the only apparent agency of infection was the bite of a coyote, led to experiments which have demonstrated the susceptibility of coyotes ind have added the bites of infected animals to the previously known means by which human infection may be acquired. Mention of a study of tularaemia carried on at the spotted-fever laboratory at Hamilton, Mont., is made on page 36. Rocky Mountain spotted fever.—An account of the studies of Rocky Mountain spotted fever is given on pages 33-36. Tuberculosis.—The investigations were continued under the direction of Pathologist William Charles White. The plan of national research in tuberculosis which the Public Health Service is carrying on in conjunction with the National Tuberculosis Association has developed a wider scope. So little progress was made by individual 32 PUBLIC HEALTI1 SERVICE tuberculosis research that a new plan was demanded; and such a plan was devised which outlined the problems that must be solved and which apportioned each problem to an investigator highly skilled in that specific phase. The plan is mobilizing widely varying research facilities throughout the country where they exist rather than attempting to gather them together into one institution. It has worked with success and, under the direction of Doctor White, the following researches are being carried on: 1. The chemistry of the tubercle bacillus, its proteins, carbohydrates, and lipoids: The bacilli grown on a synthetic medium have been supplied by two manufacturing houses and are being analyzed by experts in six university and institutional laboratories. 2. The biology of the tubercle bacillus: The Hygienic Laboratory and one university laboratory are engaged in this study. 3. The cells of the body involved in tuberculosis: Five university laboratories are taking part in this study, besides the Hygienic Laboratory, which latter is making a study of the chemistry of the epithelioid cells in which the tubercle bacillus lives during the early period after infection. 4. Differential anatomical studies of different animals to find out the reason for the location of tuberculous lesions: These are being carried on in one university laboratory. 5. The establishment of X-ray standards: This is being conducted in three university hospitals. During the year, under the direction of the Surgeon General, a conference was held to determine a method for the standardization of tuberculin, at which were represented the Bureau of Animal Industry, the United States Public Health Service, the National Tuberculosis Association, and a group of experts who acted as a council of ' advisors. Epidemic encephaliti8.—Investigations of this subject have been carried on throughout the year by Associate Bacteriologist Alice C. Evans. The streptococcus which has been described by certain other workers as the etiologic agent of this disease was obtained at necropsy from a case which died in an acute attack. A study of the organism was made, and apparently it was found to pass through a complex life cycle, one of the phases in the cycle being a spore-forming rod. A syndrome, in many respects similar to epidemic encephalitis, was produced in laboratory animals by inoculations with this organism. The same kind of organism, exhibiting the same variety of phases and similar pathogenic properties, was obtained from the spinal fluid from two chronic cases of the disease, from the blood in an acute case, from a sample of encephalitis"virus"from England, and from five samples of "herpes virus" collected from several laboratories. Vaccination sequelm.—This investigation has been carried on by Surg. Charles Armstrong. Data were collected concerning 38 cases of postvaccinal tetanus which occurred in the United States during 1925. These studies have confirmed certain observations made earlier which have resulted in recommendations that small insertions of vaccine virus are advisable and that dressings should be avoided. These studies seem to indicate that a, high degree of susceptibility to vaccinia is essential for the development of postvaccinal tetanus, PUBLIC HEALTH SERVICE 63 complicaas in every case for which full information is available the severe. as bed y descri usuall was " tion following a primary "take vaccine in isms s organ tetanu e strat demon to ts attemp Numerous rmly unifo were etc., , media e cultur virus, using various methods, negative. carried Trachoma.—Cultural and pathological studies have beenBengt son A. Ida st iologi Bacter ate Associ by year the on throughout avails result no are There Mo. in the branch laboratory at Rolla, able to warrant any definite statement at the present time. direction Pneumonia.—This work has been continued under thehave been s Studie York. New at Cecil L. R. t Exper of Special ated laboraconducted on the duration of active immunity in vaccin is being ity immun in ytes leucoc the of role The s. tory animal definite d yielde has em probl other studied, but neither this nor the results. ally Several alleged cures for pneumonia have been tested clinic their nt warra would that s result ut witho but ly, mental and experi general clinical'use. Surg. Drug addiction.—Further field work on this subject by ts the suppor Mez Du G. A. Lawrence Kolb and Pharmacologist y exagOpinion that the prevalence of addiction is still being greatl te of estima the that ulate gerated. Evidence continues to accum high too be would 1924 in made d States Unite the in s 110,000 addict for the present time. A special study of addiction was made in a southern community. in This investigation suggested that addiction of therapeutic origin does it than ion addict all of tion propor larger a tutes the South consti in the northern communities. Typhus fever.—Passed Asst. Surg. K. F. Maxcy continued .field d States A investigations of endemic typhus in the southern Unitein the Public hed publis was e diseas the of ption descri al detailed clinic led and assemb were ations observ Health Reports. Epidemiological virus the of ty identi the ish establ to s studie atory Labor analyzed. and field the in begun were nature and its mode of transmission in . atory Labor nic Hygie the at ued contin are being CONTROL OF BIOLOGIC PRODUCTS which has Standardization of antidysenterie serums.—This work, E. M. A. st iologi Bacter ate Associ of n igatio invest major been the serum) (goat xin antito An ted. comple Enlows for several years, was in the es purpos e rativ Was prepared and a unit suggested for compa . serums ic senter antidy testing of commercial were carried • Studies on the toxins of Eberthella dysenteriae Shiga work. No the tinue discon to ble advisa to a point where it was felt into an nces substa or clear-cut separation of the toxic substance ed; effect was oxin) (exot oxin neurot a and enterotoxin (endotoxin) overlapping always occurred. manifested in Anavenom studies.—Considerable interest has been American North of venom the subject of a serum effective against the mental experi an on made been have enoms serpents. Such antiv which ly rcial comme ced basis in the past, but none has been produ experimental animals on tested when y potenc reaches a degree of of practical servthat warrants the belief that it would likely prove 64 PUBLIC HEALTH SERVICE ice in man. A difficulty in this particular field lies in the inability, under ordinary conditions,to have the serum administered sufficiently promptly to make it of value as an antidote to a poison which acts with the striking rapidity of the venoms of North American serpents. Diphtheria toxoid.—Work on diphtheria toxoid, produced by the action of formalin on diphtheria toxin, has indicated that this product is at least as effective as 0.1 L+ toxin-antitoxin mixture in the production of immunity in guinea pigs, and has the advantage of freedom from toxic reaction. Specifications for its testing have been prepared but to date no license has been issued, probably due to the disinclination of manufacturers to substitute a new product for one which has been proved by trial. Pollen extracts.—Continuation of sensitization experiments with pollen extracts in guinea pigs has shown that these products are - capable of producing anaphylaxis in these animals, which, in its manifestations in the animal, is indistinguishable from that produced by horse serum. This sensitive condition persists for more than one year. Scarlet-fever preparations.—The work on these preparations has been carried on by the assistant director. In connection with the work on the standardization of the biologic products employed in the prevention and treatment of scarlet fever, a toxin was prepared and standardized at the Hygienic Laboratory. This toxin is now in use for distribution to the manufacturers of biologic products as a control toxin with which toxins intended for the market may be compared. For a better standardization of the antitoxin, investigations were made to determine a satisfactory method of preparing stable antitoxin for distribution as a standard for comparison. Samples of different antitoxins were dried in ampules preparatory to distribution to several research workers who have indicated their willingness to assist in the determination of potency. Tests of biologic products Product Diphtheria antitoxin Tetanus antitoxin Botulinus antitoxin Antipneumococcus serum Antimeningococcus serum Antidysenteric serum Miscellaneous serums Vaccine virus Rabies vaccine Antityphoid vaccine Miscellaneous vaccine Diphtheria toxin antitoxin mixture Diphtheria toxin (Schick test) Pollen extracts • Tuberculins Scarlet fever streptococcus antitoxin Scarlet fever streptococcus toxin for Dick test Scarlet fever streptococcus toxin for immunization Erysipelas streptococcus antitoxin Total Combined total 1 Passed on record of manufacturer's tests. For sterility 54 54 3 53 82 17 66 14 29 44 357 166 11 34 53 19 16 21 1 1,094 For potency 70 55 1 33 97 19 10 52 152 89 (1) (1) () 1 578 1,094 1,672 PUBLIC HEALTH SERVICE 65 Toxicity tests Commercial samples of arsenicals Total examined 84 7 397 142 4 Arsphenamine Silver arsphenamine Neoarsphenamine Sulpharsphenamine Sodium arsphenamine 634 Total STUDIES IN PATHOLOGY The work carried on in this section falls into two divisions: (1) Study of the gross and minute pathology in connection with researches carried on by the different investigators in other sections and divisions of the Hygienic Laboratory; and (2) the study, from the point of view of pathology, of material removed at operation or during post-mortem examination. The material coming under (2) is received chiefly from marine hospitals. Specimens routinely examined Heads for rabies Urine Tissue Water Wassermanns Sera (tularaemia) Sera (miscellaneous) 68 102 303 52 ____ 1,907 179 49 Blood counts Cultures (identification)________ Catgut (sterility) Miscellaneous Total 30 100 30 21 2,841 DIVISION OF ZOOLOGY The work of the Division of Zoology was conducted under the direction of Prof. C. W. Stiles. International Commission on Zoological Nomenclature.—Cooperation with the International Commission on Zoological Nomenclature has continued in the same manner as in preceding years. The various governmental departments have frequently referred questions to the Division of Zoology for opinion. Index catalogue of medical and veterinary zoology.—The second number of the host catalogue appeareji during the year under the title "Key Catalogue of the Worms Reported for Man." This bulletin has been in such demand that a special congressional reprint was issued as House Document No. 16. The third number will go to press early in the next fiscal year, and other numbers will follow. In preparing the catalogue of infections of the primates (apes and monkeys), the point has developed that the names for the experimental (laboratory) primates are far from uniform. An attempt was made in this catalogue to reduce this confusion. Examination of intestinal 'parasites for diagnosis.—As in previous years, specimens have been examined for various Government hospitals, State boards of health, universities, and practicing physicians, and reports have been made of the findings. 14656-26 6 66 PUBLIC HEALTH SERVICE DIVISION OF PHARMACOLOGY Following are the principal investigations of the Division of Pharmacology, under the direction of Prof. Carl Voegtlin: Study of drug8 for treatment of syphilis.—The extensive work dealing with comparative sterilizing power of the most important. arsenicals is almost completed. The results clearly indicate that Ehrlich's conception of the action of these remedies is essentially, correct. There is all reason to believe that the drug kills the parasites directly. This is in conflict with the view of others that the drug in some obscure way stimulates an immune body production. The work, furthermore, supports the concept of the intensive treatment and indicates that the so-called lymph gland transfer is a better criterion of cure than the reinoculation test. The deplorable toxic reactions which sometimes follow arsenic treatment suggested the search for drugs which might prevent such reactions. The results of recent experiments indicate that sodium hyposulphite (which is known as a remedy for arsenic dermatitis, etc.) does not decrease the parasiticidal action of the arsenicals in experimental syphilitic infection. The simultaneous use of hyposulphite and arsenicals.may, therefore, prove of practical value in the prevention of toxic reactions due to the arsenicals. Cancer studies.—This work was carried out along the same lines as last year. A number of chemicals were studied as to their influence on tumor growth. This included also colloidal lead, which was recommended by Blair Bell and his associates of the University of Liverpool. All of these carefully performed experiments have yielded negative results. Nutritional studies.—Extensive experiments with rats have shown that autoclaved yeast evidently contains a hitherto unrecognized dietary factor. Elaborate studies were also made on the influence of changes in the vitamin content of the diet on the susceptibility of animals to certain poisons. It was found that vitamin deficiency greatly increases the toxicity of certain poisons. Permeability studies.—The penetration into Valonia (a marine alga) of certain oxidation-reduction indicators, developed by the Division of Chemistry, was investigated under various conditions of hydrogen ion concentration and light rays. It was found possible to estimate the oxidation potential of the sap of a living cell directly. Biological significance of g7utath,ione and cystine.—Previous work had shown that these important constituents of tissues are in some way or other concerned in oxidation reduction. A careful biological analysis indicates that the poisonous action of prussic acid is due to an interaction of this substance with the glutathione of the tissues. This work has thrown additional light on the obscure problem of the mechanism involved in the biological utilization of oxygen in showing that the glutathione system is an essential factor. The interesting discovery was made that isolated smooth muscle (intestine) can be sensitized to cysteine. This observation is bound to assist in the elucidation of the physiology and pathology of smooth muscle. Drug addiction.—Pharmacologist A. G. DuMez, who has collaborated with Surgeon Kolb in this investigation, resigned toward the end of the year. This study is referred to on page 63. PUBLIC HEALTH SERVICE 67 Miscellaneous.—Pharmacologist DuMez represented the Government at the International Conference for the Unification of Heroic Remedies held at Brussels in September. This conference adopted the recommendations of the Second International Conference for the Biological Standardization of Remedies, which was attended unofficially by the chief of the division. The work of this latter committee has resulted in great progress in the biological standardization of pituitrin, digitalis, insulin, arsenicals, etc. Its recommendations are being adopted in this and other countries for the official control of these important remedies. DIVISION OF CHEMISTRY The Division of Chemistry, under the direction of Prof. W. Mansfield Clark, conducted investigations in the following subjects: Oxidation-reduction processes.—Having demonstrated by investigations, reported in previous years, that certain chemical reactions between organic compounds can be conveniently formulated in terms of the transfer of electrons and experimentally measured with electrical methods, the Division of Chemistry has extended its studies to the following specific subjects: Benzidine and other colorless compounds of analogous structure are transformed to lightly colored "oxidation products" by processes involving withdrawals of two electrons from each molecule. The oxidation product then combines with the residual "reductant" to form a highly colored substance, and it is the production of such highly colored substances which is utilized in a variety of biochemical tests and staihing reactions. In the design of benzidine— and. similar reagents, in the discovery of conditions governing the color production and in the interpretation of the signficance of the results of the application of these reagents there has heretofore been no guide but empiricism. There have now been established' quantitative data and a precise formulation of equilibrium states in the reversible oxidation-reduction of such systems. Thus there has been outlined the conduct of one of the most complex systems yet investigated. However, the'very complexity which is thus revealed, when considered in conjunction with serious consequences of the instability of these systems, shows definitely that benzidine— and similar reagents are unsuitable for the many purposes for which they are now used. The study of these benzidine types of systems was made possible by the ability of the electrical methods to reveal transitory equilibrium states. As the methods are pushed further toward the investigation of reactions accomplished in the normal or pathological metabolism of the living cell, the study of transitory equilibrium states becomes of greater importance. Consequently considerable time has been used in the synthesis of compounds designed in the hope that they will provide favorable materials for such studies. Previous investigations of reductive tendencies in suspensions of living cells were consolidated and embodied in a paper on the subject, the tenth of the series." Aside from several important implications of theoretical importance set forth in this paper, there is 9 Supplement No. 54 to the Public Health Reports, 1926. 68 PUBLIC HEALTH SERVICE described a method of experimentation which will probably be used extensively. As reported last year, preliminary studies of the use of electrical potential methods in following disinfection by iodine and chlorine were found to be of suggestive value to the theory of disinfection in general and to the chlorination of water supplies in particular. Accordingly, more systematic investigations were begun by an investi gation of the "chlorine electrode." In a sense incident to researches on oxidation-reduction previously reported, but having their own intrinsic values, are the researches being conducted upon the organic chemistry of the materials used. A compilation of literature upon reactions used in tests for phenolic compounds an experimental demonstration of the two-stage nature of the widely used Millon's reaction, and the development of an extreme& delicate new test for phenol are developments which will be reported separately when brought nearer to completion. A specific test for cysteine.—An increasing appreciation of the importance of sulphur metabolism, normal and abnormal, has made it advisable to continue the study and the application of a specific test for cysteine previously reported. It is now possible with this test to distinguish cystine cysteme, glutathione, etc. Acid-base equilibria.— formulation of the main features of acidbase equilibria in milk was made. Improvements in the preparation and purification of new acid-base indicators were aids to commercial production. Proteolytic enzymes of bacteria.—Synthetic culture media in which reproducible values for the gelatinase formed by Proteus vulgaris (Bacillus proteus vulgaris) were constructed and the influence of calcium and magnesium upon the production of gelatinase was studied. Analysis of arsenicals.—The Division of Chemistry has charge of the chemical analysis of arsenicals, the manufacture of which is licensed by the department. In general a high standard in the chemical qualities of these products has been found by the tests of the last fiscal year. In certain instances the application of the new methods of determining the distribution of sulphur in the sulphurarsenicals has given evidence that particular preparations are not wholly of the type the manufacturer intended to produce. Lead analysis.—The Division of Chemistry took part in the investigations concerning the possible hazards in the use of tetraethyl lead by conducting an extensive series of analyses. These are reported elsewhere. Miscellaneous.—Assistance was given to the pellagra studies by analyses of feeding materials. Standard solutions were prepared for other divisions of the Hygienic Laboratory or for other offices of the service. Some 251 miscellaneous analyses were made. Several memoranda upon various subjects were prepared in answer to requests of correspondents or other offices of the service. Assistance was given to the investigation on malaria by the preparation or the procurement of materials to be tested as mosquito larvicides. Bibliographies on hydrogen ion concentration and anaerobic culture methods were kept up to date. 0 Supplement No. 55 to Public Health Reports, 1926. . PUBLIC HEALTH SERVICE 69 VIRUSES, SERUMS, TOXINS, AND ANALOGOUS PRODUCTS The provisions of the law of July 1, 1902, governing the manufacture, importation, and sale of viruses, serums, toxins, and analogous products have been carried out under the supervision of the Director of the Hygienic Laboratory and under the immediate direction of Surg. W. T. Harrison. This control work has been of great value to the public in securing for them pure and potent biologic products and in preventing their exploitation by worthless preparations. Thirty-seven domestic and 11 foreign establishments held licenses under this law at the, close of the fiscal year. There are now 98 different biologic products licensed for interstate traffic. An account of the investigations relating to these products conducted at the Hygienic Laboratory is given on pages 63-65. COOPERATION WITH STATE BOARDS OF HEALTH In addition to the foregoing references to investigations made under this division at the request of and in cooperation with the health organizations of a number of States, the following investigations were made during the year: An investigation by Surg. G. C. Lake of an outbreak of a disease in southwest Virginia, which proved to be a glandular febrile type of tularwmia investigations by Surg. Charles Armstrong of an outbreak of poliomyelitis in Louisville and other places in the State of Kentucky and of a milk-borne outbreak of septic sore throat in Brunswick, Ga.; a study of communicable-disease control in the State of North Carolina, by Surg. Thomas Parran, jr. the examination of a case of typhus fever in Richmond, Va., by Surg. Joseph Goldberger • and an investigation of a case of suspected leprosy in C., by Surg. G. W. McCoy. Goldsboro, IV. MISCELLANEOUS The results of the studies made by the Scientific Research Division have been brought to the attention of health agencies and the public by the distribution of its publications, conferences with health authorities, addresses at meetings, and by means of correspondence and press articles. An important work of this division is the reviewing of scientific papers and articles on public-health subjects prepared by service officers for publication. During the past year this work has included 3 Hygienic Laboratory bulletins, 6 Public Health Bulletins, 5 supplements, and 94 articles submitted for Public Health Reports or outside scientific journals. The details of the representatives of the Public Health Service to meetings of scientific and public-health associations have been arranged through this division. In many cases papers are given presenting the work of the service, particularly the results of its investigations. DIVISION OF DOMESTIC (INTERSTATE) QUARANTINE In charge of Asst. Surg. Gen. W. F. DRAPER The activities of this division during the past fiscal year to suppress epidemics and to prevent the interstate spread of disease have included: (1) Plague-suppressive measures; (2) activities for the eradication of trachoma; (3) the conduct of studies and demonstrations in rural sanitation; (4) the investigatioa of sanitary conditions of areas used for growing shellfish for shipment in interstate traffic; (5) the carrying out of service policies for the prevention of epidemics by assisting State health departments in establishing and improving local health service; (6) the improvement of sanitary conditions in the national parks; (7) the control of water supplies used for drinking and culinary purposes by interstate carriers; (8) supervision over sanitary and health conditions on interstate carriers; and (9) mosquito-control measures along the Texas-Mexican border to prevent the spread of yellow fever should it be introduced. PLAGUE SUPPRESSIVE MEASURES IN CALIFORNIA Plague suppressive measures in California may be considered under the followinc, divisions: (a) Plague in bLos Angeles. (b) Plague in Oakland. (c) Ground-squirrel control in the field. (d) Rodent survey and sanitary inspections in San Francisco. (e) Pathological and bacteriological examinations in the Public Health Service laboratory. PLAGUE IN LOS ANGELES The Public Health Service assumed charge of the plague suppressive measures in Los Angeles, Calif., on June 16, 1925. On October 1, 1924, pneumonic plague made its appearance in Los Angeles. From October 1, 1924, to January 10, 1925, there were. reported 33 cases of pneumonic plague, with 31 deaths, and 8 cases of the bubonic type, with 3 deaths making a total of 41, of which 7 occurred in the county of Los Angeles. Two recoveries from pneumonic plague were recorded, the diagnosis in each case being based on clinical evidence only. Upon the recognition of the disease, the city board of health took inunediate steps to enforce measures for the control of the epidemic. A quarantine area was established, all persons suffering with the disease were immediately hospitalized, and contacts were placed in strict quarantine. A general campaign was instituted by the State board of health for the control of rodent plague, consisting of trapping, poisoning, 70 • PUBLIC HEALTH SERVICE 71 disinfecting, and wrecking, followed later by rat-proofing. The• work remained under this direction until June 2, 1925. During this period 190 rats and 9 squirrels were found to be plague infected. The epizootic, however, was not confined to the city, 76 infected rats and 2 ground squirrels having been collected in the county of Los Angeles. On June 3, 1925, the city board of health assumed control of the work, and conducted the campaign until arrangements could be made for assistance from the Public Health Service. During the months of May and June, 1925, several meetings were held at which the general plague situation, methods of control, and finances were discussed. The meetings were attended by a representative of the Public Health Service, members of the board of health of the State of California the board of health of the county of Los Angeles, and the board of health of the city of Los Angeles; also representatives from the larger community bodies in the city. Resolutions'were formulated, introduced, and adopted, to invite the Surgeon General of the Public Health Service to take charge of the plague eradicative measures. There were no objections. An invitation was then forwarded to the Surgeon General from the mayor of the city of Los Angeles. Asst. Surg. Gen. Rupert Blue, who was on the field, was directed to take over the work June 16, in cooperation with the city department of health, and 10 commissioned officers were immediately ordered to Los Angeles to assist him. These officers, several of whom had had experience in plague suppressive measures, had arrived and were assigned to their respective duties on or before July 15, 1925. From June 16 until July 1, 1925, the activities consisted mainly of taking over the personnel, checking, reconditioning, and listing all supplies and equipment, purchasing new material and equipping personnel, preparatory to reorganizing. July 1, 1925, may be stated as the official date for the beginning of operations. Organization.—Upon assuming charge of plague-eradicative measures, Asst. Surg. Gen. Rupert Blue established headquarters at 1015 East Eighth Street, a centrally located building with sufficient space for offices and a laboratory. It did not provide, however, storage rooms and yard space for supplies, materials, and transportation. This space was provided at District No. 9, located at 1807 East Seventh Street, a short distance from headquarters. The staff of the medical officer in charge was composed of Surg. Carroll Fox, in charge of the laboratory; Surg. H. F. White execu' Surg. tive officer, and the''following-named officers for field work: T. J. Liddell, Surg. J. G. Wilson, Surg. Carl Michel, and Surg. H. E. Trimble; Asst. Surgs. Carl K Rice, E. E. Huber, A. S. Rumreich, and J. T. Harper; and Acting Asst. Surg. J. J. Mahoney. Acting Asst. Surgs. Benjamin Blank and Joseph A. Wagner were employed for the inspection of the dead. Pharmacist Paul C. Jones acted as chief clerk at headquarters. An officer was placed in charge of each district, to whom was assigned a force of employees consisting of stenographers, inspectors, foremen, and trappers. The plan of organization adopted in Los Angeles was that of.the San Francisco campaign of 1907, which organization had also given 72 PUBLIC HEALTH SERVICE satisfactory results in New Orleans and Texas, and which is believed to be well adapted to the conditions usually found in large American cities. Fumigators, wreckers, poison distributers, hunters, and miscellaneous personnel were attached to headquarters, to be assigned for temporary duty in the various districts as needed. All of the personnel, paid from local appropriations except the inspectors, was secured from the eligible civil-service list of the city, the officer in charge having no discretion in the selection of the same, and in many instances men were assigned to duty who were not qualified by education or experience for the positions. Owing to local civilservice regulations, many difficulties were experienced during the campaign in the direction and discharge of personnel. Inspectors were selected at headquarters and assigned to districts for duty. With few exceptions the men were proficient and their services satisfactory. It may be pertinent to remark here that in selecting an emergency force it would be in the interest of efficiency and economy if some provisions could be made whereby civil-service regulations could be waived. Each officer was provided with an office centrally located in the district, and was furnished with a clerical force and means of transportation. The sanitary district was the unit of field operations, subject to direction from headquarters. Each district operated as a unit for trapping, rat-proofing, and the handling and treatment of infected foci. Daily reports were required from each district giving the rat catch, a summary of rat-proofing, and wrecking which had been accomplished. A personnel card was also submitted daily to headquarters for tabulation. City of Los Angeles and its environs.—The city of Los Angeles, at present comprising about 420 square miles, extends along the Pacific Ocean, with the ports of Wilmington and San Pedro, the recreation city of Venice, a short stretch along the foot of the Santa Monica Mountains; thence through Topancra Canyon to Calabasas along the Simi foothills; thence along the base of the Santa Susana and San Gabriel Mountains; and south in an irregular line to Wilmington. Within its boundaries are smaller incorporated municipalities such as Santa Monica, San Fernando, and the independent incorporated towns of Hawthorne, Inglewood, and Torrance. Adjoining its boundaries are larger incorporated municipalities such as Burbank, Glendale, Vernon, and the cities of Pasadena and Long Beach. The elevation within the city boundaries varies from sea level to about 300 feet at the city hall, and to an elevation of about 1,700 feet near San Fernando. While Los Angeles lies on a general slope from the San Gabriel Mountains to the sea, the sloping contours are broken by high hills such as Griffith Park and Beverly Hills, and by numerous shallow ravines, while the Los Angeles River traverses the greater part of the city. Los Angeles has an equable climate throughout the year. It has an average rainfall of about 10 inches, with little or no rain during the summer months. The city in area is one of the largest in the United States. It has a population of over 1,000,000. PUBLIC HEALTH SERVICE 73 One of the greatest difficulties experienced during the campaign was to cover the large territory with a limited personnel. There have been added, in recent years, many scattered subdivisions and many annexations of adjoining incorporated towns. The city has a large commercial and metropolitan district. The older districts are greatly congested, and many of the buildings were serious menaces as rat harborages. The residential sections spread over a large portion of the area and, generally speaking, were found to be relatively free from rats. In the open areas squirrel infestation was heavy. The ports of San Pedro and Wilmington presented practically the same conditions as found in the city of Los Angeles. The docks along the water fronts were, in most instances, rat-proofed and rela, tively free from rodents. Conditions were not found in the ports to justify a conclusion that plague was introduced through maritime shipping. Legislation.—In conducting the plague eradicative measures in the city of Los Angeles, the question of legislation immediately arose. The authority upon which the work was to be accomplished was based on ordinance No. 50282, which had been passed by the council of the city of Los Angeles, and signed by the mayor on November 21, 1924. The ordinance provided sanitary regulations for the protection of public health in the city of Los Angeles, and particularly to prevent the propagation and spread of bubonic plague through the medium of rodents. It covered such phases of the work as entering and inspecting and the abating of nuisances, for the elimination of rat harborages and the protection of food products. It provided for rat-proofing in a general way, but neglected to specifically set forth the proper methods to be used, the latter being left to the discretion of the health officer. It was not a strong law, nor a law to be desired for this important phase of the work. A new ordinance was immediately drafted covering all the points in ordinance No. 50282 and also embodying specific instructions in regard to the rat-proofing which would be required on the various types of buildings in the city, and was presented to the authorities for consideration and adoption. Owing, however, to opposition on the part of the building department, some community bodies, and the prejudices of certain officials, it was not possible to secure the enactment of desirable legislation during the fiscal year. Pending the adoption of a new ordinance, regulations were drafted setting forth in detail the necessary requirements, and with the consent of the health commissioner this phase of the work was developed and has been carried on throughout the year with excellent results. No affidavits have been filed against property owners. The adoption of a new ordinance that would insure rat-proof construction in future building has been the subject of numerous conferences between the Public Health Service, the city authorities, the chamber of commerce, and certain nonofficial improvement associations. As a result of these meetings, a preliminary draft of proposed amendments has been approved and forwarded to the city attorney and the building commission for consideration and transmission to the council. TAlthough the draft does not embody all 74 PUBLIC HEALTH SERVICE the suggestions made by the service, there can be no doubt that it carries substantial improvements which will correct many of the imperfections of the old building code. The amendments originally recommended were based upon the habits of the three dominant species of rats found in Los Angeles that is to say, burrowing, climbing, colonizing, gnawing, and migration. The present status of legislation is that ordinance No. 50282, without consultation with or consent of the health officer of the city of Los Angeles, or consultation with representatives of the Public Health Service, has been repealed, effective July 1, 1926. The repeal of this law has left the health department without legal authority to proceed with emergency work unless general police power can be invoked to meet insanitary conditions as they arise from time to time. At the close of the fiscal year the city of Los Angeles was free from plague, 85 to 90 per cent of the business places were in a rat-proof condition, and rodent infestation was reduced, but with no legislation providing for rat-proofing in any manner, a condition to be deplored. Publicity.—The plague campaign was taken over by the Public Health Service eight months after the original outbreak, when there were no human cases occurring and plague in rodents was showing up at irregular intervals, a situation which dissipated any favorable public sentiment. The public was indifferent. The newspapers were only neutrally friendly ,and no publicity was to be had from any source whatever. In order to inform the public it was necessary to hold many public meetings, at which representatives of the Public Health Service and the city board of health talked on the subject of plague and eradicative measures. At least 60 meetings were addressed, and these were largely attended by interested property owners. Information which was furnished in the addresses was well received and did much to create favorable sentiment. Had it not been for public speaking, very little rat proofing could have been accomplished. The citizens were very prompt in responding to requests made of them and showed a fine spirit of cooperation. In fact, there has been no opposition worthy of mention from the property owners to the rat-proofing campaign.. Laboratory operations.—The laboratory was directed by Surg. Carrol Fox from July 1, 1925, to March 19, 1926, at which time he was succeeded by Bacteriologist L. V. Dieter, who remained in charge until the close of the fiscal year. The personnel consisted of 1 commissioned officer, 1 bacteriologist, 1 assistant bacteriologist, and 5 dissectors. There were delivered to the laboratory during the year 255,720 rodents, as follows: Mus norvegicus Mus alexandrinus Mus rattus Mus musculus Citellus g. fisher! Miscellaneous rodents 58,189 11,783 10,156 123,434 35,629 16,529 All rodents received at the laboratory, with the exception of a greater percentage of mice and the putrid specimens, were dissected and examined closely for pathological lesions. 75 PUBLIC HEALTH SERVICE Beginning July 11, 1925, the rats received at the laboratory, regardless of species, were dissected and of those in not too advanced. stage of decomposition, portions of the spleen and liver were removed and mass inoculations made into guinea pigs. In the greats majority of instances each inoculation was confined to the tissue from 10 rats. Besides the mass inoculations, rats showing suspicious usly, lesions were inoculated separately into guinea pigs, subcutaneo cutaneously, or both. From November 19, 1925, mass inoculations were also made from ntall squirrels brought into the laboratory and from a certain perce tus. age of Mus museu The number of guinea-pig inoculations were as follows: Number Number Number Number Number Number 89 12 104 4,204 1,030 230 suspicious rats inoculated suspicious rats inoculated (positive plague) single inoculations (special) mass inoculations (60,144 rats) mass inoculations (19,461 squirrels) mass inoculations (4,927 mace) 5,669 84,751 Total number of inoculations Total number of rodents inoculated Plague-infected rats were reported from the following Location Date reported locations: Type inoculation Number rats in group ) ( i ,I July 31, 1925 Aug. 13, 1925 Aug. 22, 1925 Sept. 22, 1925 Sept. 29, 1925 Oct. 2, 1925 Oct. 12, 1925 Nov. 6, 1925 Various locations 315 South Broadway 312 South Broadway 704 North Broadway 2773 West Pico 704 North Broadway 2773 West Pico 327 Marchessault Total plague-infected rats Group Single Group Single do Group do do • 14 1 1,32 1 1 2 3 2 1,2 12 1 Reported as I plague rat each. 2 Varied. 3 Norway. gross lesions and to inIn order to find infection not indicated byof rodents mass inoculaer sure the examination of a greater numb the laboratory workers. tion was adopted as a routine measure by enumerated above does not The number of guinea pig inocluations necessary, both in order were that ions include a number of reinoculat obscure cases and because of to confirm the diagnosis of plague inof organisms that were found er numb the fact that a considerable no suspicious lesions) would (even in rats and squirrels showing ce lesions that were susprodu pigs when inoculated into guinea ions, and in some instances picious enough to warrant reinoculat before a negative diagnosis sary neces several reinoculations were could be established. d many organisms that resemThe laboratory workers encounterethe rodents examined. Chief bled B. pesti,s, morphologically, infied as belonging to the rat paraidenti among these was an organism ntly harbored by rats without protyphoid group, which was evide inoculated into animals would producing visible lesions, yet when 76 PUBLIC HEALTH SERVICE duce small hemorrhagic buboes and swollen spleens and livers, which also showed a peppering of pin-point necrotic areas. Smears made from these showed the presence of bipolar organisms, morphologically B. pestis, others shorter and atypical, necessitating a series of reinoculations. In the reinoculations plaguelike lesions would be greatly accentuated and the virulence of the organism enhanced both in the tissues and cultures obtained from the tissues. Death would occur in guinea pigs from cutaneous inoculation in from five to six days, with lesions closely resembling plague. The final determinations were made on cultural characteristics. It is quite probable that the presence of this group of organisms in the rat population can be accounted for more or less by the unauthorized use of several biological rat exterminators on the market. Several strains of Gram negative streptococci also were encountered. These produced in inoculated animals an intense hemorrhagic and gelatinous, stringy, mucouslike edema, resembling very closely acute plague lesions. These lesions, however, were more easily ruled out as plague because, of course, cultures and smears showed it to be definitely a streptococcus infection. In a large colony of rats taken from a garbage dump located near the city was found a pathological condition the nature of which has not been fully determined. Fifteen per cent of the rats showed enlarged, swollen spleens peppered with pin-point areas of necrosis closely resembling subacute plague as found in guinea pigs. Many experiments were undertaken with a view to demonstrating the nature of the lesions both by animal inoculation and feeding, but with negative results. ' Attempts to obtain cultures from the lesions were also uniformly negative. One other organism, B. myxoides, produced lesions resembling acute plague when,inoculated intraperitoneally into a guniea pig. Smears made from the peritoneal fluid showed innumerable organisms practically indistinguishable from B. pestis. Determination could be finally made from cultures. Tularemia was found in wild rats on three separate occasions. It was encountered last in a group of rats caught on September 15, 1925. This is believed to be the first time that the disease has been so reported. Considerable work has been done in order to determine the length of time that the rat could harbor virulent B. tularense without showing lesions. At the close of the fiscal year it had been found that rats inoculated subcutaneously had harbored the organism for 87 days without any ill effects. This experimental work has not been completed. Flea survey (1925-26). Owing to the difficulty of obtaining properly trapped specimens, only a partial flea survey was made in the laboratory. The following tables give the results of the survey as far as carried out: Table 1 Total rats examined without fleas: R. norvegicus R. rattus R. alexandrinus 116 6 10 77 PUBLIC HEALTH SERVICE Total rats examined with fleas: R. norvegicus R. rattus R. alexandrinus 546 10 11 699 ' Total rats examined for fleas Fleas identified as follows: Xenopsylla cheopis Ceratophyllus fasciatus 2 Ceratophyllus acutus Ctenocephalus canis Leptopsylla musculi Hoplopsyllus anomalus Pulex irritans 2,446 or 50 or 43 or 15 or 107 or 21 or 3 or Total fleas identified Average fleas per rat 2,685 3.8 91.09 per cent 1.86 per cent 1.62 per cent .55 per cent 3.98 per cent . 78 per cent . 11 per cent Table 2 Date July August September October November December 1925 Percentage of predominant types Number Number of fleas of rats examined found X. cheopis C.fasciatus C. acutus L. musculi 55 114 63 224 188 93 80 474 140 686 866 417 62.50 87.70 72.80 97.22 95.80 86.80 7.50 1.60 14.30 .58 .23 2.40 .63 .29 1.02 1.73 2.87 29.90 5.70 7.80 .73 1.96 6.20 A number of other animals were examined for fleas, including foxes, wild cats, skunks, opossums, weasels, field rats and field mice, gophers, etc. A number of interesting specimens were procured and Surgeon Fox reports the finding of several entirely new species, and at least one new genus. Inspection, of the dead.—The inspection of the dead was under no the direction of the officer in charge of the laboratory. Although 1925, 10, y Januar since d reporte been had plague human cases of all it was considered necessary that a careful check be made on ed. confirm death of cause the and nature, deaths of a suspicious Acting Asst. Surgs. Benjamin Blank p.nd Joseph A.. Wagner were until employed for this purpose and were on duty from July 1, 1925, of the February 15, 1926. By arrangements with the undertakers diagnocity, they investigated 3,057 deaths, in order to rule out the inued sis of plague in any form. This phase of the work was discont the last after a period of four months had elapsed from the date of plague infected rat (November '6, 1925). during Endemic plague.—No human cases of plague were reported general hosthe fiscal year. There were, however, investigated at the cases of pital, three suspected cases of bubonic, and two suspected but not the one rat mentioned 1 Total count includes January, 1926, rats and fleas, below. west Sixth Street, a residence, 707 at trapped was s In January, 1926, one R. norvegicu As there were nearly 3.6 times as and was found to be infested with 181 C. fasciatus. during the preceding six examined rats all on found many fleas on this one rat as were January count in the above figures. months, it would be misleading to include the 78 PUBLIC HEALTH SERVICE pneumonic plague. These were found to be negative after a careful checking in the laboratory. Epizootic plague.—During the fiscal year the laboratory reported positive plague rats from six different locations in the city of Los Angeles, all of which, with the exception of the rats from 312 and 315 South Broadway, were widely separated and no connection could be traced between the foci. The greatest distance between any two foci was about 5 miles. The connection between the locations from which positive rats were taken from 315 South Broadway and 312 South Broadway will be dealt with later. The diagnosis of plague in rats was made by group inoculations in six instances and by single inoculations in three instances. None of the rats which were proved to be positive showed lesions of acute plague. The lesions varied from those of subacute plague to those showing no gross signs. The causative organisms seemed to be attenuated in virulence and required a series of inoculations through guinea pigs in order to establish a diagnosis. The determination of each case was confirmed not only by animal inoculation but by cultural methods as well. Trapping operations.—Trapping has been the most reliable procedure by which infected rodents were located and the amount of infection determined during the campaign. It furnished an index of the rodent population by species and has been largely responsible for the reduction of the rodents generally. To trap properly an area of 420 square miles many factors had to be considered before a definite procedure could be outlined, namely, the limited trapping force, the large number of premises, and the extensive vacant territory, besides the migratory and other habits of rodents. It was therefore concluded that to locate and eradicate the infection it would be necessary to cover the territory as a whole and not in sections only. Trappers were assigned to districts in numbers corresponding to the size and nature of the territory which had to be covered. They were divided into squads of six each, over which was placed a foreman. To each trapper the following property was issued: Two hundred snap traps, a few cage traps, a bucket, an oil can, a file, and a brush, for which property he was held responsible. Bread was used as bait and was supplied daily to the trappers. The trapping force was so limited that it was impossible to assign men ill sufficient numbers to each district to cover the city simultaneously. It was therefore necessary to move the trappers in rather definite lines, by progressively stepping the traps forward from one side of a district to the other, in order to be assured that no premises would be missed. The catch was collected daily and delivered to the laboratory for examination. The number of trappers in the field varied from 183 on September 18, 1925, to about 25 at the end of the fiscal year. The trapping force was maintained at the highest point of efficiency at all times. . Each trapper was paid a salary of $130 a month. No bounty could be offered as an incentive to insure a standard daily catch. A daily, report card was used, whereby the efficiency of the individual could be determined. Rodent catch.—A total of 255,720 rodents were collected during the fiscal year, as follows: PUBLIC HEALTH SERVICE Total rodents collected Total rats collected Total squirrels collected Total mice collected Total rodents examined Total rats examined Total squirrels examined Average daily rodent catch Number of trapping days Number of trapper days Number of rodents per man per day Number of rats and squirrels per man per day Number of infected rodents (all Mus norvegicus) 79 255,720 96,657 35,629 123, 434 106,936 67,801 34,208 849. 5. 301 34,340 7.44 3.85 12 ted and the The difference between the number of rodents collecthe fact that by for nted accou is number examined in the laboratory the putrid, mutionly a small percentage of mice were examined and ned. exami be not lated, and other rodents which could city, commonly The wholesale and manufacturing district of the proportion large a shed furni ct, spoken of as the commercial distri ing and proof rat of t adven the With ted. collec ts of the total roden them of made sts reque s to owner prompt compliance of the property of end the at low very was it until ned decli ily the rat catch Stead the from taken were mice, t the fiscal year. Very few rodents, excep This section was commercial district during May and June, 1926. The other sections city. the of on once the most heavily infested porti but had a large of the city were not very heavily infested with rats, rel infestasquir The ts. roden proportion of mice and miscellaneous . areas open the tion was heavy in not very heavily The ports of San Pedro and Wilmington were has been conports the from catch rat The ts. infested with roden rel infestasquir the ver, Howe sistently small during the fiscal year. adjoinially espec and s, limit city the n withi areas tion in the open year. the ghout ing the ports, has been very heavy throu m of tunnels by - In the metropolitan district there existed a syste central heating one from d heate which many large buildings were long distances over y freel l trave could ts roden plant and in which 5 feet in about were ls tunne The from one building to another. run. were pipes steam which gh throu , width in height and 3 feet mile. e squar 1 of area an in ms There were at least 10 of the syste rats, and in the All of the tunnels were found to be infested with proved to be was ls tunne the of case of the Bradbury system one the Grand From foci. ted infec two en betwe link the connecting located at es, Angel Los in t marke Central Market, the largest retail from the ts roden and thous al sever taken were , dway 315 South Broa were many which of 1924, 1, beginning of operations November dically from perio ring appea tion infec the ted, infec proved to be February 22, 1925, to August. 13, 1925. trapped in this location, On August 13, 1925, an infected rat was by the trappers working ed locat which was the first infected focus trapping and other under the Public Health Service. Intensive tuted in the market insti y iatel methods of plague control were immed of tunnels were ms syste d groun under The s. and adjoining block heating system al centr the with cted explored and all buildings conne methods. were subjected to the same intensification of trapp ed in a restaurant On August 22, 1925, an infected rat was , which is opposite the dway Broa South 312 at ing located in a build .80 T:iBLIC HEALTH SERVICE Grand Central Market, across a wide, busy thoroughfare, but connected with it through the central heating system. The market had been a constant source of infected rodents from February 22, 1925, and not until all the buildings and tunnels on the Bradbury heating system were handled and treated as one infected focus was this .dangerous situation eliminated. No infected rats were taken from any of the buildings, including the market, subsequent to the finding of infection on August 22, 1925. Wrecking.—Wrecking was confined to immediate premises and adjoining properties from which infected or suspected rodents were taken. It has consisted in most instances of the removal of rat harborages only, that is to say, wood floors, double walls, and ceilings! Many requests were received for the complete demolition of buildings, owing to a policy which had been established previous to the advent of the Public Health Service. A small percentage of the requests were granted. It has been found that the demolition of buildings in plague work is not a good policy. It is expensive, time consuming, and devoid of any great benefits. During the acute stages of an epizootic the prime object of wrecking is the removal of rat harborages over wide areas around foci of infection, the elimination of potential harborages, and the collection of rodents which have not escaped from the area and which may have died of plague. The work should be very carefully supervised in order that it may be effective and at the same time economical. In the city of Los Angeles 412,587 square yards of planking were removed from premises which had been potentially dangerous. All rubbish was taken away in trucks and each premise left in a safe condition. Approximately 1,400 truck loads of rubbish were removed, representing about 1,200,000 cubic feet. Poisoning.—From June 1 until June 24, 1925, approximately 600,000 pieces of poisoned bait had been distributed in properties located in the commercial and semiindustrial districts of Los Angeles and along the banks of the Los Angeles River. Only 169 rats were found poisoned. The Public Health Service discontinued the use of poison on the latter date. Poison should not be distributed during the acute stages of the epizootic. The us6 of biologic rat exterminators produces lesions in rodents similar to those of plague and the laboratory diagnosis is thus confused and made difficult. These substances should not be sanctioned because of the possibilities of food contamination. It is believed that the dissemination of infectious agents among rats is accompanied by danger to man. Trapping should be the chief method of locating plague-infected rodents, and should not be interfered with by the use of poisons of any nature. An objection to poison is also made on the ground that some rodents.thus poisoned will die in locations which will prevent them from being collected. and the chance of locating an infected focus may be missed. The general distribution of poison, if it is to be used in a plague campaign, should take place after the amount of infection has been determined and the infected area delineated. The value of chemical poisons as aids in exterminating rodents, however, should not be underestimated. Poisons are very useful in defective sewers, in rat-proof buildings subsequently infested, and for trap-shy rodents in all PUBLIC HEALTH • SERVICE 81 localities. The measure should be employed several months before the termination of the work, with a view to reducing the residual rat population to a figure which, for lack of a better term, may be called the irreducible minimum. From May 10, 1926, to the end of the fiscal year 24,230 pieces of poisoned bait were distributed in the same territory that had been previously poisoned, including all public and private dumps. The following rodents were collected: 140 Mus norvegicus, 104 M1,18 alexandrinus, 48 Mus rattus, and 113 Mus musculus, making a total of 405. Of the large number of poisoned baits which were carefully placed only 1,196 pieces had disappeared. While the number of rats thus killed and collected appears small, it may be safe to assume that a large percentage of the baits which disappeared would account, in each instance, for at least one rodent, as experiments have shown that only a small quantity is necessary in order to kill. Fumigation.—Fumigation with hydrocyanic gas was used to a very limited extent, and only where there was no danger to human life. In a focus of infection located at 704 North Broadway, which had been fumigated with cyanide, there were collected approximately 60 rodents, some of which were proved to be plague infected. While cyanide gas has not been used routinely in Los Angeles, it is believed to be an excellent means in handling infected foci generally, and should be used wherever it is permissible to do so. Carbon monoxide obtained from gases escaping from the exhaust of an automobile has been found to be very effective. The use of it was made available by a general connection fitted to a flexible pipe of rather large size and to the exhaust of an automobile. The gases were then forced through an opening made in wooden and concrete floors. In many instances a large number of rodents were collected, and in two foci thus treated rats were found which were positive for plague. It is believed that carbon-monoxide fumigation should be used in all instances before wrecking work is begun. Rat-proofing.—Rat-proofing was begun during the month of August, 1925, after trapping, wrecking, and other emergency work had been well developed. Ordinance No. 50282, an emergency ordinance, which was passed by the city council on November 21, 1924, provided for rat-proofing in a general manner only, but did not embody specifications of rat-proofing as they might apply to the various types of buildings in the city. of Los Angeles. Regulations were drafted setting forth all of the principles of rat-proofing in detail, conforming closely to the ordinance published by the Public Health Service. They were submitted to the health commissioner of the city of Los Angeles for approval and adoption. The work was carried on under legal authority of regulations based on the above ordinance. This arrangement was not desired, but was the best that could be obtained under the circumstances, and there was a constant fear throughout the year of a congtitutional test in the courts. In order to institute a general rat-proofing campaign it was necessary to divide the various types of buildings into three major classes, namely, food depots, nonfood depots, and stables, each to be ratproofed in a different manner. The food depots were required to have concrete floors, which were to be protected by a wall extending 18 inches into the ground and 12 inches above the floor. All open- 82 PUBLIC HEALTH SERVICE ings in the superstructure were to be closed in a manner so as to prevent the ingress or egress of rats. Nonfood depots were to be rat-proofed by constructing a continuous wall around the building extending 18 inches into the ground and upward beneath the floor. The wall was to be at least 6 inches in thickness and of a material impervious to rats. All openings in the superstructure to be handled in the same manner as in the food depots. Stables were required to have concrete floors and a protecting wall, special provisions for the protection of food, handling of manure, etc.' All property owners were served with notices calling their attention to the defects which existed on their properties and were notified as to the requirements for correction of the same. Thirty days were allowed in which to make the necessary changes. Upon completion of the work a formal abatement was issued and data were obtained relative to cost. A fine spirit of cooperation was maintained throughout the year. Particular attention was given to the business places, food depots, and nonfood depots, and to residences in the commercial, the metropolitan, and the old congested sections of the city. Very few notices were served on other residential properties. Court proceedings were found to be unnecessary. Summary of the rat-proofing work Number of inspections Number of reinspections Number of notices served Number of abatements issued Number of food depots (concrete floors) Number of nonfood depots (continuous wall) Number of nonfood depots (by elevation) Number of food depots and nonfood depots (by minor repairs) Number of square yards of concrete Number of linear feet of chain wall Total cost By concrete floors By continuous wall, elevation, and minor repairs 34, 104 101,305 27, 262 15,596 3,050 3,011 726 8.809 415,653 723,661 $2,619, 146.27 $968, 789.63 $1,650, 356.64 The above totals do not include the amount of rat-proofing on premises which had complied, in part only, to notices served nor does it take into consideration the amount, of rat-proofing which had been done on premises on which no notices were served. Ratproofing in new constructions is not included. It is estimated that the total expenditure by the property owners in the city of Los Angeles would exceed $3,000,000 if the full records were available of the amount of rat-proofing that has been accomplished. • It may be stated that the premises was the unit for issuing abatements in the campaign. In many instances from six to ten nuisances existed and were corrected on the property before an abatement was issued. No records were kept of the number of the minor nuisances corrected. Ground-squirrel extermination.—No effective method of squirrel extermination has as yet been devised. The distribution of poisoned grain, shooting, and the use of carbon disulphide in burrows were the means employed during the course of the work. •Nithough many thousands were destroyed and large tracts of land apparently cleared of the pests, observation showed that they reappeared in the course of a month or two. 83 PUBLIC HEALTH SERVICE The question arises as to whether reinfestation occurred through migrations from distant centers or whether, the animals subsequently observed were not survivors of the original colony. The amazing fecundity of the Citellu,s is also a factor that must be considered in connection with this phase of the problem. Data recorded during a period of six months showed that the total number of foetuses of females dissected in the laboratory equaled the total number of squirrels collected-the females representing about 53 per cent of the number. The same rule held true of the rats examined. There can be no doubt that. the habit of estivating, or hibernating, for long periods greatly increases the difficulty of exterminating squirrels by means of gases and other poisons, because the animal when in a state of torpor requires little oxygen and no food or water. It is believed that estivation can be assumed at will as a means of defense against adverse conditions which arise from time to time in the struggle for existence. The employment of a more lethal substance, such as hydrocyanic gas, would give better results, and an effort should be made to find a safe method of preparing and applying it. At any rate, the choice of a gaseous exterminator should be made in accordance with the habits of the animal and with a view to asphyxiating its parasites as well. Neglect of the latter precaution could well be the cause of the continuance of epizootic infection. Good results have been reported by the State horticultural commission following the use of poisoned grain and other methods in various counties. The recurrence of epizootic plague, however, indicated that either infected squirrels or infected fleas survived the operations and lived long enough to spread infection to succeeding generations. Monthly summary of squirrels examined in laboratory between July 1, 1925, and June 30, 1926 Month July August September October November December January February March April May June Total 1925 1926 Per AverTotal cent PregPer Per age preg- number number nant cent cent of foeti males females females nant of foeti females Males Females 3,932 2,931 2,919 2,336 1,257 • 1,698 1,979 1,437 1,372 1,098 591 798 1,953 1,494 1,547 1,238 666 900 3,100 2,601 3,601 2,626 2,727 4,480 1,457 1,222 1,625 1,145 1,292 2,123 1,643 1,379 1,976 1,481 1,435 2,357 45. 1 43.6 47.3 47.4 54.9 56.4 52.7 52.6 560 655 1,389 746 492 267 234,208 116,139 18,069 47.0 6.o 4,233 Total 50.3 49.0 47.0 49. 7 51 I 53 31 14 4 3 1 71 267 112 30 25 7 575 8.61 8.0 7.5 8.33 7.0 8.09 34. 1 47. 5 70. 29 50.37 34. 28 11.32 5,215 5,458 12,003 5,785 3,328 1,867 9.31 8.33 8.64 7.75 6.76 6.99 23.4 34,672 1.58 0.937 .25 .24 .15 8.00 (19 of sex were not kept in the laboratory I During the months from Sept. 1, 1925, to Feb. 28, 1926, records of basis 53 per cent females and 47 per cent and the figures as represented above were calculated on thefor months of July and August, 1925, and the males to females of ratio the males, which was arrived at by March, April, May, and June, 1926. of 1,421 2 Total brought in by hunters, 35,629; total examined in laboratory, 34,208. The difference were unfit for examination represents number of squirrelg which,due to laceration and rapid decomposition, and dissection. during year, 15; minimum, 4. Mean average. 7.94; average from totals, 8.42. Maximum number 84 PUBLIC HEALTH SERVICE Cooperation. with, the city department of health.—For the fiscal year ended June 30, 1926, the city of Los Angeles appropriated $325,000; the Federal Government allotted $120,000, not including the salaries of commissioned officers. It was necessary to make arrangements with the health commissioner for a liaison officer so that amicable relations could be established and expenditures made in conformity with existing laws. By effecting this arrangement assistance was rendered in securing personnel and furnishing transportation and supplies, the latter being purchased through the city health department. Ample transportation was available throughout the year, and no trouble was experienced in securing supplies. Dr. George Parrish, the health commissioner, and his department were active in the matter of securing favorable sentiment, better legislation, and appropriations. They were untiring in their efforts to secure the cooperation of the various departments of the city government, which was necessary to insure the success of the campaign. The service also appreciated the cooperation rendered by Mr. James Woods, chairman of the health and sanitation committee of the chamber of commerce, who gave a great deal of his time to committee meetings and to other efforts to secure the support of the general public. Smallpox.—A smallpox epidemic of considerable proportions occurred during the course of the campaign. It began in October or November, 1925, and reached its highest stage in February, 1926. The outbreak was not confined to any one section, but was widely scattered throughout the city. More than 1,278 cases were reported, with 200 deaths. Of the cases treated in the hospital 50 per cent were of the confluent or hemorrhagic types. Upon the request of the health commissioner an officer was detailed to assist in vaccinating school children and in rendering such other aid as his duties would permit. It is stated in the health commissioner's report that "less than 20 per cent of the patients came from the foreign population, including the Mexicans." ATTITUDE OF THE STATE AND COUNTY BOARDS OF HEALTH Early in July, 1925, a communication was addressed to the president of the State board of health informing him that the Public Health Service had assumed charge of plague eradicative measures in Los Angeles upon the request of the city administration and suggesting a conference for the purpose of considering a definite plan of cooperation between the authorities concerned. In his reply, dated July 9, 1925, the president accepted the offer of cooperation and stated that a conference would be called at an early date in Los Angeles. This meeting was held in the State board's headquarters in Los Angeles July 13, 1925,'and was attended by the State and county health officers and Assistant Surgeon General Blue and Surgeon White, of the Public Health Service. Definite proposals were made by Doctor Blue for a joint investigation of conditions in Los Angeles and adjoining counties, with a view to delineating infected areas that migh have escaped detection during the first survey or which might have been reinfected through subsequent migrations of infected PUBLIC HEALTH SERVICE 1 ( ( 85 rodents from Los Angeles. It was pointed out that the defense of Los Angeles against plague was dependent more or less upon rodent infestation of adjoining towns and rural districts. During the course of the conference the county health officer seemed inclined to accept the suggestion, but stated that the policy of his board would be in this instance defined by the State board of health. The State health officer withheld his decision and announced that the matter would be brought to the attention of his board for consideration and action. No answer has as yet been received from the State health officer relative to the proposals discussed at that time. Following the conference a letter was forwarded to the president of the State board expressing regret at the failure of the conference to recommend a cooperative plan- whereby the two services could work toward a common end. No satisfactory explanation of the State's attitude on this important matter has ever been given. The board had no funds for antiplague work and had been forced to request an additional appropriation of $500,000 from the city with which to defray the cost of operations. In April, 1925, the city council instructed the health commissioner to demand control of the municipal "rodent-extermination division" from the State on grounds which it deemed to be just and proper. This letter was unanswered. However, upon the receipt of a second request, dated June 1, 1925, the State withdrew, leaving the situation in the hands of the local department of health. Although it was generally known that infected foci existed in Los Angeles, the county authorities discontinued plague-suppressive measures on July 1, 1925, regardless of the fact that large numbers of rats could still be trapped on the refuse dumps maintained by some of the incorporated towns. Hermosa Beach is a conspicuous example of this type of community. Trappers who visited these dumps at irregular intervals secured in each instance large catches of Norway rats. It is of interest to note that some of the Hermosa rats exhibited plague-like lesions from which an unidentified organism was isolated. Complete monthly reports covering the operations of the Public Health Service in Los Angeles were Forwarded to the State board of health from the inception to the completion of the work. The finding of plague-infected rodents was reported by letter immediately following laboratory confirmation, the date location, and numbers being given so that a spot map of foci could be prepared from the information supplied. The facilities of the plague laboratory at 1015 East Eighth Street for purposes of instruction were placed at the disposal of the State and county boards. Assistants in the county health offices of Orange, Ventura, and Riverside Counties, and the city of Long Beach visited the laboratory and received instruction in methods of determining plague in rodents, etc. Recommendation8.—Under date of June 14 a communication was addressed to tIle health commissioner stating that the service would withdraw on June 30, 1926, and emphasizing the importance of continuing certain antiplague measures indefinitely in order to prevent a recurrence of the disease in Los Angeles. The activities recommended were as follows: (1) That trapping operations and labora- 86 PUBLIC HEALTH SERVICE tory examination of rodents be continued as routine measures; (2) that the building code be amended in such way as to provide for ratproof construction; (3) that provision be made (under general police power) for the elimination of rat harborages and rat 'colonies wherever found; (4) that antirat installations be considered a sanitary prerequisite in granting permits for the conduct of business places; (5) that a modern system of refuse collection and waste disposal be installed; (6) that an arrangement be made with the county authorities whereby similar measures will be enforced in the towns and communities with which Los Angeles is connected. A copy of this letter was forwarded to the chairman of the health and sanitation committee of the chamber of commerce so that members of the chamber might inform themselves concerning the plague situation in southern California. It was pointed out that the method of refuse disposal obtaining at that time was far from satisfactory; in fact, that it was an insanitary anachronism that should be condemned at once and replaced by a modern system. Kitchen refuse, market waste, and street sweepings constitute the chief food supply of the rat population; the greater the supply the more numerous the rats. Refuse should be collected at frequent intervals and destroyed by-incineration or by a combination of methods by which the health menace would be removed, and portions of the material separated and utilized. It should be borne in mind that no system is complete or safe that does not provide for the use (in each household) of metal garbage cans with tight-fitting covers. PLAGUE IN OAKLAND The conditions under which plague suppressive measures were inaugurated and conducted in the transbay cities in 1925 were fully described in the annual report for that year. The activities were continued during the current fiscal year until March 1, 1926, at which time they were terminated. The last plague-infected rat in the campaign was captured on March 2, 1925. The total number of plagueinfected rats captured was 21. The total number of rats trapped during the entire campaign, January 1, 1925, to March 1, 1926, was 81,755, of which 72,074 were Mus norvegacus;1,139 Mus alexandrinms; 1,226 Mus rattus;the remainder were unclassified. The maximum weekly rat catch was 3,123 and was made in the week ended March 21, 1925 thereafter the catch steadily declined. In March, 1925, the trapping average per man per day was 61/5 rats, whereas in January, 1926, it had declined to 31/5 rats. It is believed that the rat population of Oakland has been reduced by at least 50 per cent in the course of the campaign. The custom of disposing of garbage by dumping along the water front gave rise to a large number of rats and favored the spread of plague infection among rodents. Until these dumps could be thoroughly cleaned up and a more satisfactory method of garbage disposal inaugurated there was no assurance that plape would not recur. During the current fiscal year the dumps were entirely eliminated and two scows were obtained by the city and are now used in carrying garbage to sea, where it is dumped some 40 miles from land. This method appears to be entirely satisfactory. The PUBLIC HEALTH SERVICE 87 old garbage dumps have been eliminated partly by fire and partly by covering with sand. Further acknowledgment is made to the various officials and the city governments in the east bay communities for their cordial cooperation which was maintained from begihning to end throughout the campaign and which made it possible to obtain satisfactory results. PLAGUE SUPPRESSIVE MEASURES IN CITIES AND COUNTIES IN VICINITY OF SAN FRANCISCO BAY In this report consideration will be given only to those activities carried out .in the city and county of San Francisco, San Mateo, Alameda, and Contra Costa Counties. The plan of these activities has been similar to that in past years and will be considered under the following headings: (a) Plague in ground squirrels and rodent-control measures. (b) Rodent surveys and sanitary inspections in San Francisco. (c) Operations of the Public Health Service laboratory. Plague in ground squirrels.—There is believed to be no change in the status of plague infection in ground squirrels, and it is probabl6 that shooting operations carried out for the purpose of determining the foci of infection would demonstrate that this disease continues to exist over a large section of California, extending from the Carquinez Straits on the north to Los Angeles County on the south, and embracing the central and coast counties in this area. There have been deaths from plague among the ground squirrels in San Luis Obispo County, and one infected rat was found in this area, the infection probably having been acquired from contact with infected squirrels. Plague has been definitely proved in ground squirrels in San Benito County. Out of 27 forwarded from an area in the southern part of that county, 5 were found infected with plague. Plague infection has been continuous in this particular area, as one human case occurred in 1920 and another in 1921. Report has also been received that a child in this same locality was taken sick with a high fever and enlargement of the glands in the axilla. This in all probability was a mild case of bubonic plague that recovered. It has not been possible to carry out any shooting operations during the year on account of the limited appropriation available for this work. The State has been unable to contribute any financial aid for these operations and the allotment was sufficient only to permit carrying on the work in the four counties in which control measures • are being exercised. The continued existence of numerous foci of plague in ground squirrels over a large area in the 'State of California constitutes a perpetual menace to public health. It will never be eradicated under the present methods of operation, because they are not extensive enough to make a definite impression toward eradication of these foci of infection. Field operations too control of ground squirrels.—The activities directed toward the control of ground squirrels have been limited to the four counties in which work was contracted in 1921. It was believed that the funds available could be most advantageously ex- 88 PUBLIC HEALTH SERVICE pended in limiting the work of control measures to the districts around centers of population in the bay region for the purpose of maintaining a squirrel-free zone. In two of these counties the employees of this office have operated in conjunction with the employees of the county horticultuFal commissioner, the agency in charge of county control measures. In addition to the activities of this office, limited operations are being carried out in some of the other counties by the horticultural commissioner. These measures, however, are not always continuous and effect little more than nominal control. The amount of work performed varies in different counties, and in the majority practically nothing is being done. If plague infection is ever eradicated in the ground squirrels of California, it will be accomplished only by an intensive, coordinated effort, covering the entire area known to have foci of infection over a period of at least three years. Active shooting operations to determine foci of infection and active eradicative measures in and around these foci would eventually eradicate the disease. Work of this magnitude would require a large appropriation, and unless such appropriation be made available by the State or county authorities the present situation will probably continue or grow more menacing. The field operations were as follows: 23 Number of inspections Number of reinspections 5,.653 Number of acres inspected 4,031 1,862,507 Number of acres reinspected Number of acres treated with waste balls 67,514 Number of acres treated with grain 252,010 Number of holes treated with carbon bisulphide 389,122 Material used: Number of pounds of poisoned grain 134,652 Number of gallons of carbon bisulphide 6,743 Number of waste balls used 391,257 Number of pounds of poisoned barley mixed for private landowners under supervision of employees of the service 61,609 Experimental work with calcium cyanide: Acres of land treated 185 Number of burrows treated 300 Pounds of calcium cyanide used 1371? A further use has been made of calcium cyanide in selected areas for the purpose of determining efficiency, in comparison with carbon bisulphide, in the destruction of squirrels, as the two agents are used under similar conditions. The use of this material by open-hole method has not been proved as efficient as when the opening of the burrow has been closed. In event the latter is required, the calcium cyanide is as .expensive .as carbon bisulphide, without being as valuable a destructive agent. Measures taken against rats.—A- rodent survey has been continued in San Francisco during the year, and there have been employed six trappers, four engaged by the city and two Federal employees. The work, at the request of the city health officer, has been carried out by this office and the rats caught are examined in the Public Health Service laboratory ' here. During the year there have been approximately 1,500 traps in continuous operation, and the number of rats caught was 36,839. The trapping operations have been most successful, and this survey has been maintained at a cost of about $7,000 to the city and the salary of two Federal employees. PUBLIC HEALTH SERVICE 89 In addition to trapping, limited poisoning operations were carried out for the purpose of treating vacant lots, lumber piles, etc. 111,200 baits were placed. The classification of the rats has been transferred in this report to the section on the operation of the laboratory. It will be noted that a proportionately large number of Mus alexandrinus and Mus rattus have been trapped. These, when compared with the percentage of the same species trapped in Oakland, will give an indication of the more satisfactory rat-proof conditions in San Francisco against Mus norvegicus. San Francisco probably has a larger percentage of rat-proof buildings than any other seaport in the country. This is largely due to the extensive campaign of 1907 and 1908 and the continuous operations since that period for the condemnation and rat proofing of infested harborages and insanitary premises. These activities are shown below: Number of premises inspected 16,325 Number of nuisances abated 2,663 Number of compla:nts investigated 1,628 Number of garbage cans installed 1,348 Number of premises cleaned of rubbish 458 Number of floors torn up 322 130 Number of buildings destroyed Number of stables destroyed 7 Measures taken for the permanent rat proofing of old buildings, including food places: 335 Number of buildings rat proofed by concreting 23 Basements concreted (square feet, 45,700) 312 Floors concreted (square feet, 533,665) 3 Yards, passageways, sidewalks, etc., concreted (square feet, 1,580)_ square feet__ 580,950 Total area concrete laid do____ 8,380 Total area walls installed Number floors rat proofed with double floors and wire cloth be18 tween (square feet, 29,250) Sanitary inspections in San Francisco.—The sanitary inspections in San Francisco are of complaints referred from the city health department and from other sources. Rat complaints Chicken, rabbit, pigeon, etc., complaints Garbage and defective garbage cans Rubbish cdmplaints Plumbing complaints Insanitary premises, including shacks Stench complaints Goat, dog, and cat complaints Mosquito, fly, and flea complaints Miscellaneous 905 155 80 52 3 176 6 3 5 243 Nom—All the above complaints were investigated by the inspectors, the necessary notices prepared and sent out, and reinspections made to determine whether the existing nuisances were abated. Condemnation proceedings 145 Number of buildings submitted to board of health for condemnation 95 Number of buildings acted on by board of health and condemned 1150 Number of buildings acted on by board of health and not condemned Number of buildings abated following condemnation proceedings (by re119 pair, 1; by demolition, 118) 107 Number of buildings condemned and remaining unabated n These include some buildings acted upon during previous years; hence totals will not balance. 14656-26 7 90 PUBLIC HEALTH SERVICE Operations of Public Health Service laboratory in San Francisco.— The policies of the laboratory and the general scope of its activities have been continuous with those practiced in former years, involving the examination of rodents to determine the presence of plague, clinical-microscopical examinations requiring facilities not immediately available to other stations of the service and to other governmental departments, and the investigation of the diseases of man. The examination of rats collected in Oakland, Calif., under the supervision of the service was continued until March, 1926, and subsequently a smaller number collected daily by the Oakland Board of Health has been extunined without the finding of plague infection. The examination of ground squirrels collected from the immediate environs of Oakland was also made without the finding of plague infection. The examination of rats collected in San Francisco, under the supervision of the service, has been continued throughout the year without the finding of plague infection. A few ground squirrels were submitted for examination by the county horticultural forces of San Benito County, and in one shipment of 27 collected from the southern end of the county, 5 were found to be plague infected. Of these, 1 was in a subacute stage of infection and 1 in an acute septicemic stage. Clinical-microscopical, bacteriological, or serological examinations were made for the United States marine hospital and relief stations at San Francisco and San Pedro and for the immigration and the quarantine stations at San Francisco, and active clinical assistance was rendered the United States marine hospital at San Francisco during an acute outbreak of smallpox, and bacteriological examinations of water were made for.the United States Veterans' Bureau and for the United States Lighthouse Service. Cooperative experimental investigations were made with the plague laboratory of the service at Los Angeles, Calif., in determining the presence of infections in rats with bacterium tularense. The courtesy of the laboratory and active assistance have been extended the Hooper Memorial Foundation and field material has been supplied in investigations to determine the prevalence in rats of bacteria of the typhoid group and to determine the identification and classification of other bacteria-producing lesions in rats which resembled those of plague. Similarly aid was given in studies being made in the department of zoology of the University of California by making observations and compiling data on the breeding season of Norway rats in San Francisco. The personnel of the laboratory has also delivered lectures to the students in public hygiene of the University of California and has made addresses to local county medical societies and to a scientific society on epidemic work conducted by the service. Experimental investigations have been made in the methods of immunizing against smallpox, in which approximately 500 tests were made, and a local outbreak of the disease was studied and reported. Also investigations are being conducted with strains of B. pestis collected from tarbagans, ground squirrels, and rats to determine their probable relationship to the production of plague pneumonia in guinea pigs, and observations on rat leprosy are being 91 PUBLIC HEALTH SERVICE made in the attempt to establish the infection in white rats and to determine the constancy of leprosylike bacteria in the nose of the wild Norway rat. Studies in the development of the clonorchiasis have been continued along the lines elsewhere reported. Classification of rats Rath from San Francisco: -Mos morvegicus Mus rattus Mus alexandrinus Total .28,209 3,576 5,054 36,839 Rats from east bay cities: -Mus norvegicus Mus rattus Mus alexandrinus Total 26,824 ' 633, 744 28, 201 summary of laboratory operations Examination of rodents for plague: Rats from San Francisco Rats from Oakland, Alameda, and Berkeley Rats from fumigated ships Mice from Oakland, Alameda, and Berkeley Ground squirrels Total number rodents examined Received Examined 36,839 28,201 1,893 1,201 2,702 32,313 26,501 1,893 1,201 2,702 70,837 64,611 Serological examinations: Wassermann reactions Widal tests Total Bacteriological examinations (cultures and microscopic): Blood Feces Urine Throat cultures Other body fluids Suture material Water examinations Total Bacteriological examinations with animal inoculations: Tuberculosis Rodent plague Total Squirrels, positive for plague Parasitological examinations Histological examinations Vaccines 3,249, 12: 3,261 126 1 2 9 34 2 66 15 105 120 5 1 88 2 PLAGUE ERADICATIVE MEASURES IN NEW ORLEANS, LA. The rodent survey with which this report is concerned was begun in New Orleans in December, 1924, following the recognition of rodent plague in rats trapped along the water front during the latter part of November, 1924. Between December 2, 1924, and January 17, 1925, 12 rats were found to be plague-infected. No other infection was demonstrated, though 156,000 rats were examined. During theperiod covered by this report the ,work was in charge of Surg. C. V. Akin. PUBLIC HEALTH SERVICE 92 tion and The trapping and examination of rats and the fumiga ted prosecu y activel was vessels of ng guardi rat and off g fendin 1925. 30, June ended throughout the fiscal year A TRAPPING OPERATIONS 1925, the Trapping force—Effective the close of work on June 30, e of 135 averag an at ined mainta been had trapping force which originally instimen was reduced to 85. The plan of squad districts trappers, and 2 chief or; inspect acting One tuted was adhered to. trappers dis10 foremen supervised and directed the activities of 70 tributed in 10 squads. d by Trapping area.—With the reduction in force the area covere manner the though ted, restric rily necessa trapping operations was the catch in which this was accomplished was designed to maintainfront and water , vessels ng Incomi point. at the highest possible intenwharves, and all known rat-plague foci were provided for and n the betwee lying zone the hout throug sive trapping was assured and river and St. Charles Avenue above Canal Street and the river withy entirel were Traps Street. Claiborne Avenue below Canal long drawn from certain areas which had yielded small catches for than g less yieldin s district in kept periods and trappers were not three rats per man per day for longer than one week. 1, Rodent catch.—During the period covered by this report, July total A days. ng trappi 75 were there 1925, 30, ber Septem 1925, to of 63,34.6 rodents were trapped,fumigated, and found dead, of which number 38,707 rats were examined in the laboratory. A comparison of the total catch with the number of trapping days utilized shows the following daily averages: Total rodents captured Total rats examined Trapping days Trappers (daily average) 63,346 38,707 75 71 Average daily rodent catch Average daily rat catch Rodents per man per day Rats per man per day 844.6 516.0 11.9 7.2 B. LABORATORY OPERATIONS Laboratory.—All rats were examined in the"rodent-plague laboratory" under the direction of Dr. W. H. Seeman, bacteriologist for the State and city boards of health. There were no changes in procedure or personnel in the laboratory during the period under consideration. Examination of rats.—Of a total of 38,707 rats examined, 233, or 0.6 per cent, were considered suspicious for plague. None of these, however, proved positive on biologic test. Distribution of rats examined by species and sex Species M.norvegicus M.rattus M.alexandrinus Total Total Per cent Per cent Female Per cent 16,863 641 1, 123 48.6 42.9 44.8 17,839 856 1,385 51.4 57. 1 55.2 34,702 1,497 2,508 89.7 3.9 6.4 18,627 48.2 20,080 51.8 38,707 . 100.0 Male PUBLIC HEALTH SERVICE. 93 Plague rat.—By the conclusion of the survey on September 30, 1925, approximately eight and one-half months had elapsed since the reporting of the last plague-infected rat on January 17, 1925. This observation is of the greatest significance when considered together with the fact that during this time 156,000 rats were carefully examined by inspection, smear, culture, and inoculation.. C. OUTGOING QUARANTINE During the fiscal year ended June 30, 1925, three phases of outgoing quarantine procedure were prosecuted. Throughout the period from December, 1924, to June 30, 1925, all vessels entering and docking in the port of New Orleans were required to fend off and rat guard, but successive modifications of the fumigation requirements applicable to vessels because of the presence of rodent plague in New Orleans were recommended to and approved by the bureau as the time interval after the finding of the last plagueinfected rat on January 17, 1925, increased. Effective July 1, 1925, coastwise vessels docking in New Orleans were required to fumigate under Public Health Service supervision, only once in 90 days. On July 18, 1925, six months after the notification of the last. infected rat, the, Public • Health Service officially declared New Orleans to be free from rodent plague, and all restrictions incident thereto were removed. Fumigation of vessels.—The quarantine fumigation plant, under the immediate supervision of Acting Asst. Surg. R. E. Bodet, transferred from the jurisdiction of the New Orleans quarantine station to that of plague-eradicative measures on December 10, 1924, remained on the latter temporary status until late in September, when it became definitely established that the rodent-plague survey and eradicative measures would be discontinued, effective September 30, 1925, if no other infection should be demonstrated. The agreement with the New Orleans Steamship Association, entered..into on January 1, 1925, by which certain necessary fumigating personnel would be furnished and stipulated expenses for motor transportation upkeep and operation met by that organization, was kept in effect until September 30, 1925. This action, taken in the face of the fact that the actual fumigation demands diminished rapidly after the opening of the port, is typical of the generous and whole-hearted cooperation constantly displayed by the association. Fumigating personnel.—In addition to the service personnel regularly assigned to New Orleans, consisting of 1 'medical officer, 1 chief fumigator, and 7 assistant fumigators, 14 additional fumigators furnished by the steamship association were retained on duty until June 30, 1925. Effective July 1, 1925, 4 association fumigators were discontinued as a means of equalizing expense, in view of the fact that fewer vessels were being entered for fumigation under the 90-day modification. The association fumigating force was further decreased on August 15, 1925, when 6 additional men were discontinued. This reduction was accomplished with no loss in efficiency, as the complete removal of plague restrictions on July 18, 1925, made fumigation necessary '94 PUBLIC HEALTH SERVICE only for such vessels as entered New Orleans subject to the terms oof a provisional pratique. At the solicitation of the medical officer in charge, the steamship association agreed to the retention of the remaining 4 fumigators pending action by the bureau on a recommendation that the regular service fumigating force be increased by 4 additional men. This recommendation was approved, and, effective October 1, 1925, the New Orleans fumigating organization consisted of 1 medical officer and 12 men, which number provides two independent fumigating squads, thus doubling the capacity of the plant. Vessels fumigated.—From July 1 to September 30, 1925, 122 vessels were fumigated with hydrocyanic-acid gas by the barrel method. This represents a daily average of 1.3 vessels, or one-third of the average established for the period December 16, 1924, to June 30, 1925, during which time the peak load incident to the actual presence of plague was experienced. It should be stated that "averages" in this connection are misleading, as they in no wise typify the daily peak so often encountered. In the production of an average of 1.3 vessels days showing; four fumigations are included as well as days on which no fumigations were done. If fumigation is to be accomplished without .seriously interfering with shipping, it is obvious that a fumigating organization must be maintained calculated to meet the ordinary peak load without undue strain. The average cost of fumigation per vessel was approximately $70, the amount established during the rush period December 1924— June, 1925. D. PORT SANITARY REGULATIONS The requirements of paragraphs Nos. 101 and 102 of the United :States Quarantine Laws and Regulations relating to the fending off and rat guarding of vessels entering and docking in a plagueinfected port were enforced rigidly until New Orleans was declared to be plague free on July 18, 1925. The force of water-front inspectors detailed to secure compliance was then reduced to one, whose activity was limited to the inspection of vessels entering New Orleans subject to the terms of a provisional pratique. During the period of three months ended September 30, 1925, 944 vessels were inspected 2,217 times. Six hundred and seventy-seven of these vessels required port sanitary statements, necessitating the issuance of 1,544 statements for additional ports of call. Of this list only eight vessels, through failure to comply with port sanitary regulations, were given "foul" bills of health. E. TRANSPORTATION Adequate transportation facilities were afforded by the several agencies cooperating in the survey. Heavy motor trucks were furnished by the Public Health Service for fumigation duty. Light motor trucks were furnished to the fumigating plant by the New Orleans Steamship Association, and mechanical upkeep and repair and a considerable proportion of the fuel and lubricating material used were also provided by the association. The New Orleans city PUBLIC HEALTH SERVICE 95 board of health furnished and maintained two light touring cars throughout the survey, one being assigned to the trapping organization and one to general headquarters use. The State board of health furnished one light touring car for headquarters use. The collection and transportation of the rodent catch from the widely separated squad district centers was accomplished easily with a small truck. After passing through the laboratory, rodents were removed to a city incinerator in this same truck. F. FINANCIAL Aside from the financial support given to the fumigation section by the New Orleans Steamship Association, the expenses of the rodent plague survey for July, August, and September, 1925, were met by the Public Health Service and the New Orleans city board of health. The amounts expended were as follows: (1) United States Public Health Service.— (a) Salaries (b) Rat bounty (c) Miscellaneous $27,551.06 4,180.20 30.00 Total 31,761.26 (2) New Orleans city board of health.—In addition to the rodent plague laboratory which was operated entirely at city expense, the city board of health provided a monthly allowance of $1,800. As this allowance was accumulative, rigid economy resulted in an unexpended balance of $5,687.79 in the rodent plague survey fund on September 30, 1925. The expenditures for the period July, August, and September, 1925, totaled $4,099.82. Grand total of all expenses of above agencies was $35,861.08. G. COST OF RODENTS TRAPPED AND EXAMINED NOTE—In order to establish with a high degree of accuracy the actual cost per rat, every item of expense incurred for all purposes of the survey has been added, including the salary of the medical officer in charge. (1) Cost per rodent, including rats and mice: Total rodents trapped Total cost of survey Cost per rodent trapped 63,346 $35, 861. 08 0. 566 As compared with the cost per rodent for the period December, 1924, to June SO, 1925, the above figure shows a decrease in operating cost of $0.065 per rodent. (2) Cost per rat delivered at laboratory for examination: Total rats examined in laboratory Total cost of survey Cost per rodent examined 38, 707 $35,861.08 0. 926 As compared with the cost per rat examined during the period December, 1924, to June 30. 1925, the above figure shows a decrease in operating cost of $0.016 per rat. H. SUMMARY 1. The last plague-infected rat in New Orleans was reported on ,January 17, 1925. 2. Between the reporting of the last plague-infected rat and the discontinuation of the survey on September 30, 1925, a total of 155,753 rats were examined, with negative results. 96 PUBLIC HEALTH SERVICE 3. The port of New Orleans was officially declared plague free six months after the finding of the last plague-infected rat. 4. Trapping operations and the laboratory examination of rats were actively prosecuted for two and one-half months after the opening of the port, during which time approximately 35,000 rats were examined, with negative results. 5. The ratio between rats examined (174,187) and plague-infected rats recognized (12) gives 1 plague rat for every 14,515 rats examined. 6. From December 2, 1924, to January 17, 1925, 12 plague-infected rats were demonstrated. These rats were captured in fapparently separate foci, 3 on ,or immediately adjacent to the water front, and 4 inland. Water-front foci.—Water-front focus No. 1 is represented by several sublocations extending over a wharf area of from three-fourths to 1 mile from Conti to Piety Streets. Six plague-infected rats were recovered from this area within about six weeks. Water-front focus No. 2 at the Washington Avenue level is located 4 miles upstream from No. 1. Water-front focus No. 3, at Stuyvesant Docks, Elevator E, foot of General Taylor Street, is in turn 1 mile upstream from No. 2. Inland foci.—These foci are listed in the order of the date when infection was reported. Inland focus No. 1 (plague rat No. 6) is located approximately 2 miles inland, at 2010 Sixth Street. This location represents the apex of a triangle, the basal angles of which lie at water-front foci Nos. 2 and 3. Inland focus No. 2 (plague rat No. 7) is located about one-half mile inland and approximately midway between water-front foci Nos. 1 and 2. Inland focus No. 3 (plague rat No. 11) is located from one-half to three-fourths mile inland and approximately midway between water-front foci Nos. 2 and 3. Inland focus No. 4 (plague rat No. 12), at 1703 Religious Street,, is located from one,fourth to one-half mile inland and without special reference to water-front foci, except that it is nearest to water-front focus No. 2. 7. Careful estimates, in which all items of expense have been included, indicate that the New Orleans rodent plague survey was conducted at a cost of slightly less than $0.95 per rat. SURMISES AND CONCLUSIONS (1) While it is impossible to conclude definitely from the experience of the survey under consideration whether this, the latest occurrence of rodent plague in New Orleans, was a recrudescence or a reimplantation, it is believed that the latter position is the more tenable. With the exception of inland focus No. 1 (rat No. 6, 2010 Sixth Street), the 11 remaining infections were on the water front or within striking distance of the wharves. For the purposes of this discussion it may be assumed that if the occurrence of rodent plague in this instance was a recrudescence infection would have been (a) more widespread, (b) less definitely associated with one zone or section of the 40 square miles of area under survey, and (c) the plagu& infections demonstrated would have been less apt to be concentrated PUBLIC HEALTH SERVICE 97 within the comparatively brief period of two months (first plagueinfected rodent captured November 22, 1924, positive December 2, 1924; twelfth plague-infected rodent captured January 15, 1925, positive January 17, 1925). The ratio between the total number of rats examined and the square miles of territory trapped shows an average of 4,355 rats per square mile. (2) As regards the mechanism of reimplantation or the specific source of infection it is possible only to advance general conclusions. Infected rats captured on and immediately adjacent to the water front were taken over a stretch of 6 miles. Along this front vessels from foreign ports dock and discharge cargo. Pursuant to the requirements of paragraphs 101 and 102 of the Quarantine Laws and Regulations such vessels discharge cargo prior to fumigation. 'Whether these vessels fend off and rat guard during discharge appears to be of no great consequence so long as the fact is established that cargo which may or may not carry plague-infected rats is conveyed to the docks. From the date of the discontinuation of plague-eradicative measures on June 30, 1923, to December, 1924, when plague was again discovered, vessels from known or suspected plague ports arriving in New Orleans followed the procedure suggested above. (3) In attempting to establish the probable time of reimplantation it may be assumed that the reinfection was of comparatively recent date. This conclusion is based on the fact that 11 out of 12 infected rats were captured on or very near the water front and the ratio or infection to total rats examined was 1 to 14,517. (4) It is not believed that the plague infection under consideration can be attributed to contamination of shore rats by the known infected rats on the steamship Atlanticos, arriving in New Orleans on. October 27, 1924, and the steamship Craftsman, arriving on November 12, 1925. (a) Neither vessel docked at all of the wharves on or near where plague-infected rats were subsequently found. (b) The time interval between the docking and discharge of these vessels, October 27 and November 22, 1924, respectively, and the appearance of plague infection in rats on the New Orleans water front from November 22, 1924, to January 15, 1925, seems insufficient to account for a dissemination of infection to rats captured from threefourths to 2 miles from where the vessels docked. In addition, it seems contrary to all probability that the infection of shore rats should have followed inevitably, that the contaminated rats should have scattered to several widely separatedpoints, and that the trapping force, which in November, 1924, numbered 12 men, should have caught the very rats in which contact had resulted in infection. (5) To summarize, it appears from the known facts and from conjecture predicated thereon, that the rodent plague infection demonstrated in New Orleans from December, 1924, to January, 1925, represented a reimplantation which was effected at some date between June 30, 1923, and June, July, or August, 1924. It seems certain that the infection was introduced nearer the latter than the former date, as the intensive survey showed that the infection had gained no great headway. 14656-26 8 100 PUBLIC HEALTH SERVICE Field operations—Continued. Number of buildings fumigated Pounds of cyanide used Pints of sulphuric acid used Total cubic feet of space fum.gated New buildings inspected; passed _Premises inspected 'Square yards of planking removed Laboratory operations: Rodents examined— Mus norvegicus Mus rattus Mus alexandrinus Mus musculus Wood rats Miscellaneous Putrid 0 0 0 0 0 0 34, 702 1,497 2,508 0 0 0 38,707 38,707 233 0 0 0 0 0 63,346 38,707 Total rodents received at laboratory Number of suspicious rats Number of positive rats Suspicious human cases examined Positive human plague cases Number of human plague cases to date Number of rodent plague cases to date Number of rodents captured to date Number of rodents examined to date PLAGUE PREVENTIVE MEASURES, SEATTLE, WASH. Waterfront Vessels inspected, for fending and rat guarding "Vessels fumigating Sulphur used -Cyanide used Muriatic acid used Number of cubic feet fumigated New rat guards installed Defective rat guards repaired Port sanitary statements issued 618 171 144,669 pounds__ 15,936 pounds__ 76,839 pints__ 49,961,000 43 150 3,218 The usual patrol was maintained to enforce rat guarding and fending on all vessels arriving from plague-infected ports. Laboratory operations Dead rats received Rats trapped and killed Rats after fumigation Total rats -Rats examined for plague infection Rats proved plague infected Blocks poisoned Poison disbursed Sanitary fills poisoned and repoisoned Classification of rodents Mus rattus Mus alexandrinus Mus musculus Mus norvegicus Average number of traps in use daily All traps are inspected daily. 15 13,867 1,145 15,027 10,477 0 13 342 pounds__ 10 770 2,818 2,109 9,330 580 PUBLIC HEALTH SERVICE 101 TRACHOMA ERADICATION WORK At the beginning of the fiscal year 1926 four trachoma hospitals were in operation at the following-named places: Knoxville, Tenn.„ Russellville, Ark., Rolla, Mo., and Eveleth, Minn. The hospital at Eveleth, Minn., was closed August 20, 1925, as the State legislature failed to appropriate necessary funds to cooperate in its continuance, Trachoma in the white population does not appear to be especially prevalent in any one part of Minnesota, but cases are reported from many widely separated parts of the State. This increases the problem of treating any considerable number of cases, as the cost: of travel is prohibitive to most of the patients, and the State had no funds to assist either in providing transportation or in the conduct of field work to locate the cases. In June, 1926, the Kentucky State Board of Health made a-. generous allotment of funds to support its request that a trachoma: hospital be established in that State. A building at Richmond', Ky., which had been bequeathed to the State Medical Society as a memorial to Dr. Ephraim McDowell by his granddaughter, Mrs. Elizabeth S. Irvine, was tendered to the service for use as a hospital. As the fiscal year ended preparations were being made to, adapt the building for this purpose. The equipment of the Eveleth Hospital will be utilized in the Richmond Hospital. Knoxville, Tenn.—The Knoxville trachoma hospital receives. patients from an area comprising practically the eastern half of Tennessee, as well as a considerable number from Kentucky. Knoxville is an important center for many railroads and bus lines, making: it accessible to all parts of east Tennessee. The cooperation of the State health department and the Knox-ville health and welfare association has made possible the con-struction of a four-room addition to the hospital, providing two wards capable of accommodating three or four beds each and two large rooms used as sitting rooms and wash rooms combined. Thus, there are separate sitting rooms for male and female patients, each equipped with large wash sinks so that patients may wash in running water. Individual lockers have been provided for towels and other toilet articles. Through the field work carried on from the hospital it has been possible to follow up a large numbef of cases treated in the hospital and through these cases to locate new ones in the neighborhood. It has been gratifying to find that the results of treatment were in almost all cases very good a number of cases were seen which had been treated several years ago and who were free from symptoms of trachoma. The home visits of the nurse afford an opportunity for instruction in hygiene and impressing the patient with the importance of treatment., and many cases come ID for treatment as the result of these visits. 1628sellville, Ark.—This hospital has cared for a large number of patients, although the building is poorly suited to hospital needs. Through the assistance of the county court and a number of publicspirited citizens, a two-room cottage has Leen purchased and moved to the hospital lot. Plumbing fixtures and lights were installed and: the building is now used as a men's sitting room and bathroom. The washbasins formerly used have been supp[anted by two wash sinks.. 102 PUBLIC HEALTH SERVICE This cottage relieves the congestion in the house and improves living conditions, but does not increase the bed capacity of the hospital. Trachoma is much more prevalent in Arkansas than was formerly believed, and most of the cases seen are of a very severe type. The clinics and field work have revealed areas of prevalence where but few of the sufferers knew of the existence of the hospital. The majority were resigned to their fate, feeling that there was no hope of relief. The instructive work carried on by the staff, of the trachoma hospital has aroused many of these people to the fact that treatment is available and efficacious,. and now the hospital is crowded and there is a long waiting list for admission. The hospital is now receiving patients from practically all sections of the State. This hospital has also admitted a number of persons from Oklahoma who were suffering from trachoma in an aggravated form. It seems probable, from the number of these cases and the reports they bring of trachoma in their neighborhood, that the disease may be quite prevalent in the white population of that State, as it is already known to be among the Indians there. Rolla, Mo.—The hospital at Rolla has been improved by the building of an addition, 12 by 14 feet, to the men's cottage in the yard, with shower, toilet, and wash sink. A wash sink for women patients has also been installed in their sitting room upstairs. These improvements increase the comfort of the patients and also make administration easier. The cost has been met from State local funds. The Rolla hospital continues to have a waiting list of trachoma sufferers applying for admission. It is unfortunate that we are not able to secure bnildings large enough to care for 40 or 50 patients, as that number could be handled without much increase in operating expense by the one doctor and two nurses now employed. This is true not only of the Rolla hospital, but of all others. At present . every hospital is full and has a waiting list of patients, many of whom are in 'urgent need of immediate treatment, which can not be given them on account of lack of room. In locating new hospitals the aim should be to secure buildings capable of accommodating at least 40 patients. Laboratory.—Associate Bacteriologist Ida A. Bengtson has continued her trachoma studies in the laboratory provided by the Missouri School of Mines at Rolla.. Smears and cultures are made from each case admitted to the hospital and some very interesting work •has also been done on sections of lid tissues. The opinion is often expressed by writers on trachoma that the acute symptoms are pro•duced by secondary bacterial invaders, such as Koch-Weeks bacillus .or pneumococcus. Results of routine examinations by Miss Bengtson of material from the eyes of trachoma patients indicate that it is very rare that the usual conjunctivitis-producing organisms predominate. They are sometimes present, but are seldom numerous. The assignment of Asst. Surg. A. S. Rumreich to make an epidemiological study of trachoma marks an important step in the study of this disease. There is great need of this kind of study, and the information gained from it will undoubtedly be of great value. In 'anticipation of the epidemiological work the case-record forms used in the hospitals and at the field clinics have been revised and enlarged, so that there is on file a considerable amount of information regarding each patient which is available to the epidemiologist. 103 PUBLIC HEALTH SERVICE These records, which were put in use about one year ago, also aid• him in his study of patients in their homes. Dispensary and hospital relief, operations, etc. Eveleth, Minn.' Knoxville, Rolla, Mo. Russellvine, Ark. Tenn. Total DISPENSARY RELIEF Old cases, all causes Old cases, trachoma New cases, all causes New cases, trachoma Total attendance Total number of treatments Average daily attendance Empaired vision from trachoma Corneal opacity from trachoma Blindness both eyes from trachoma Blindness one eye from trachoma Ulcer from trachoma Pannus from trachoma Entropion from trachoma Prichiasis from trachoma Photophobia from trachoma Conjunctivitis :x' Iaucoma Prachoma cases cured 2 415 283 356 164 771 907 2. 11 125 66 0' 6 35 137 51 40 123 88 8 9 1 1,060 849 698 154 1, 760 1,807 4.82 126 67 0 4 16 78 49 53 91 224 7 9 3,519 3,029 1, 503 437 5, 124 5,369 0 2,010 1,802 417 113 2, 527 2, 589 6.92 55 12 0 2 11 12 12 2 97 147 1 30 10 11 21 0 437 637 $311.69 13 153 145 21 4,834 6,693 $3,339.91 20 165 166 19 6,464 8, 773 $4,374. 54 13 176 177 12 4,425 6, 199 $3,119.35 56 505 509 52 16, 160 22,302 $11,145.49 0 11 10 1 0 131 135 5 15 126 97 33 6 140 92 51 21 408 334 90 34 5 32 6 66 66 1. 3 6 1 0 0 1 0 1 0 5 3 0 312 146 0 12 63 227 113 95 316 462 16 48 HOSPITAL RELIEF Etemaining from previous year kdmitted during the year Discharged during the year Remaining at close of year Days relief furnished Rations furnished ost of rations OPERATIONS leneral anesthesia ,ocal anesthesia lrattage i3ntropion Closed Aug. 19, 1925. d and found cured. Impossible to determine 2 Hospital cases which have been reexamine cured, since it is difficult to see and examine with any degree of accuracy the total number hospital for home treatment. from d discharge many of them once they are Educational work, house-to-house visits, etc. Eveleth, Minn.' Knoxville, Rolla, Mo. Russellville, Ark. Tenn. Public talks given Persons (estimated) in audiences Pamphlets on trachoma distributed House-to-house visits Persons in houses visited Trachoma cases in houses visited Schools visited Pupils examined in schools Trachoma cases in schools 105 194 899 49 20 3,155 48 6 60 0 0 0 0 21 3,486 1 19 1,580 407 7 38 7 10 1,648 10 Total 25 1, 640 512 201 937 56 51 8,289 59 Field clinics Missouri Number of clinics held Number persons examined Trachoma cases found Suspicious cases found Operations performed General anesthetic Local anesthetic Physicians present 11 1,999 383 25 113 3 110 64 Arkansas 12 900 141 20 16 0 16 55 Total 23 2,899 524 45 129 3 126 119 104 • PUBLIC HEALTH SERVICE SUPERVISION OF WATER SUPPLIES USED BY COMMON CARRIERS The cooperative arrangement with State health departments for the supervision of water supplies used by common carriers for drinking and culinary purposes has been maintained during the year. In several instances, upon the request of the respective State health officers, service engineers have assisted in this and related work. One hundred and twelve supplies were examined by the district engineers in the States of Oklahoma, Arkansas, Texas, Louisiana, Tennessee, Kentucky, Idaho, Florida, and South Dakota. This number represents an increase of 36 over the last fiscal year. Assistance along other lines was given in North Dakota, Utah, Oregon, Washington, Arizona, Nevada, Wyoming, and California. Particular attention is invited to an investigation of the significance of stock grazing on the watershed of the Walla Walla, Wash., municipal water supply, which lies within the Umatilla National Forest. Cooperation with the Forest Service in matters of this nature will be continued in the future. INTERSTATE RAILROAD WATER SUPPLIES The American Railway Association, the American Short Line Railroad Association, and all of the railroads falling within the scope of the interstate quarantine regulations have cooperated during the year in a very satisfactory manner. A significant line of work during the year by the district engineers was the examination of 21 coach yards throughout the country. Representatives of this division confer with the officers of the respective roads after investigations of this kind have been completed and submit recommendations for improvements in the coach yards. In most cases changes benefiting both the carriers and the traveling public are made. In all districts inspections of water coolers on interstate carriers were carried out for the purpose of checking the reports on such equipment which had been submitted by these carriers. Although it was impossible to make a complete check on all cars, a satisfactory cross section of equipment was included and it is to be noted that only in a few instances were coolers found to be unsatisfactorily designed. During the past year final data were obtained from a large percentage of the carriers operating in the country. The time for completing the installation of satisfactory water coolers expired on January 1, 1925, but a few railroads were unable to complete their work before that time. However, all of these companies are progressing and will be requested to furnish information as to the date of completion. Significant reports were obtained from 405 railroads. These companies reported that such of their cars as fell within the scope of the interstate quarantine regulations carried 98,253 water coolers and that all but 2,975, or approximately 3 per cent, were constructed so that the ice and the water would be in separate containers. A review of these data also shows that 75 per cent of the 2,975 coolers not satisfactorily constructed are being used on cars confined to carrying members of crews. In order that the State health departments might have a full year to complete the certification of sources reported by railroads on Janu- 105 PUBLIC HEALTH SERVICE ary 1 of each year, the tables which in previous annual reports covered the fiscal year will now be compiled so as to show the completion of certification during the preceding calendar year. The following table, therefore, shows the certifications for the calendar year 1925. It should be noted that this table is not comparable with those heretofore given. Since the greatest travel takes place from and to the larger cities in the country, and since all of the water supplies of such cities have been approved as being of satisfactory quality, the percentage of travelers safeguarded under this procedure is somewhat larger than the percentage of supplies certified might indicate. Railroad supplies [For calendar year of 19251 Source classification State Alabama Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Total PriPublic 1 vate 2 Railroad Certification status Per cent sources Pro- Provi- Action acted SatisTotal factory hibited sional pending upon 32 14 44 64 29 29 6 1 48 61 17 68 48 66 73 28 31 32 15 34 62 46 33 51 19 35 9 17 36 10 103 56 16 71 44 37 133 2 38 23 25 107 17 17 44 35 32 62 9 4 1 8 5 2 0 0 0 3 1 0 6 1 1 2 7 11 2 1 0 7 2 7 9 3 0 0 0 0 0 4 7 2 3 2 3 3 0 1 0 9 10 0 0 3 2 9 15 0 4 9 21 37 7 0 0 0 5 0 8 30 14 19 14 13 12 6 6 0 25 24 10 16 6 22 12 1 3 14 22 9 10 18 6 8 22 1 1 8 12 50 7 0 7 21 11 14 6 40 24 73 106 38 29 6 1 56 62 25 104 63 86 89 48 54 40 22 34 94 72 50 76 28 57 21 18 39 24 129 72 28 92 52 48 158 3 40 31 46 167 24 17 54 58 52 91 15 40 5 2 66 19 22 6 1 32 11 11 67 29 50 80 12 33 31 13 34 69 42 36 1 27 0 19 16 38 23 82 42 0 83 7 35 72 3 0 12 2 32 17 16 49 2 49 47 4 0 0 1 0 1 0 0 0 0 0 1 1 0 3 2 4 3 0 2 0 2 4 0 1 0 0 0 0 0 1 3 0 0 6 0 0 0 0 0 1 0 0 0 1 2 0 2 3 2 0 0 0 0 0 7 0 0 0 0 0 36 0 0 0 0 0 1 5 0 0 0 0 0 0 0 0 1 0 0 10 18 0 0 9 0 0 0 0 0 0 53 0 0 3 0 1 5 0 0 19 • 70 40 18 0 0 0 24 51 13 . 0 34 33 7 32 18 8 2 0 23 26 14 74 1 57 2 1 1 0 34 12 28 3 36 13 86 0 40 18 44 82 7 0 0 56 0 36 9 1,929 156 571 2,656 1,389 46 149 1,072 10C 21 4 6: 5] 10( 101 10( 51 lf 41 101 41 61 9: & 61 81 9] 10( 71 6, 7: 91 ( 9( 9, 91 10( 7, & ( 91 3] 7:: 41 10( ( 4: 4 5] 7] 10( 10( 101 61 41 61 1 The column headed "Public" includes supplies owned by municipalities as well as those used by municipalities but owned by private comp anies. only by the carrier and the person 2 A "Private" supply refers to a small well or spring supply used owning it. 106 PUBLIC HEALTH SERVICE INTERSTATE VESSEL WATER SUPPLIES In a manner similar to that followed in the certification of water supplies used on railroads, the parallel work of investigating and certifying supplies used by vessel companies has been done in cooperation with State health departments. The following table prepared for the calendar year 1925 shows the status of this work: Vessel supplies [For calendar year of 1925] Source classification State Alabama Arkansas California Connecticut Delaware District of Columbia Florida Georgia Illinois Indiana Iowa Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri New Jersey New York North Carolina Ohio Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Vermont Virginia Washington West Virginia Wisconsin Total Public Private 2 3 2 23 6 1 1 15 3 7 4 0 6 6 11 2 11 12 1 6 1 12 14 5 13 12 8 3 4 1 5 8 1 8 20 7 1 0 0 7 0 0 0 4 0 2 0 1 1 2 0 1 0 0 0 1 2 0 0 2 0 1 2 0 243 46 1 4 3 0 2 6 4 0 Company 2 0 0 0 1 0 1 0 0 0 3 0 1 0 0 0 0 0 2 0 0 0 0 0 2 1 0 0 1 14 Certification status Per cent sources SatisPro- Provi- Action acted Total factory hibited sional pending upon 3 2 32 6 1 1 20 3 10 4 1 7 11 11 4 11 12 1 7 3 14 14 7 13 13 10 5 6 1 9 12 1 10 26 11 1 3 0 0 5 1 1 1 3 9 2 0 4 2 8 2 11 12 1 4 1 14 7 3 12 0 4 4 0 0 4 1 1 8 2 9 0 303 139 1 0 3 0 0 1 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 3 0 0 0 0 0 0 2 32 0 0 0 19 0 1 2 1 3 9 3 1 0 0 0 3 2 0 7 2 0 13 6 0 6 1 5 8 0 2 24 1 1 100 0 0 100 100 100 5 100 90 50 0 57 18 73 75 100 100 100 57 33 100 50 71 100 0 40 100 0 0 44 33 100 80 8 91 7 154 49 1 The column headed "Public" includes supplies owned by municipalities as well as those used by municipalities but owned by private companies. 2 A "Private" supply refers to a small well or spring supply used only by the carrier and the person ,owning it. SUPERVISION OF WATER-SUPPLY SYSTEMS ON VESSELS The work under the direction of the district engineers has continued as in the past. Due to the addition of temporary inspectors to several districts during the summer months a greater volume of work has been made possible. Material assistance in detecting unsatisfactory water-supply systems on vessels has been rendered by State and city health departments and the service by the analyzing of samples of water taken 107 PUBLIC HEALTH SERVICE directly from the boats. Three thousand one hundred and six samples were analyzed and reported by cooperating laboratories during the year. Last year 154 cases of typhoid fever were reported to district offices as originating on vessels engaged in interstate traffic. This year only 103 cases were reported. It is questionable whether this entire reduction should be credited to the improvement of watersupply systems on vessels and other advances in ship sanitation, but unquestionably some portion of it may justly be attributed to this work. The district offices continued to receive and review plans of vessels intended for interstate operation before such vessels are launched. This procedure, which should be encouraged and developed, eliminates the necessity of changing fixtures on boats after they have been received by the owners and placed in operation. The Steamboat Inspection Service has cooperated effectively during the year by submitting reports on vessels inspected. The following table prepared for the calendar year 1925 is the first of its kind ever included in annual reports. It gives the status of vessel water-supply systems certified throughout the country: Vessel water supply systems [For calendar year of 1925] District 1 2 3 4 and 6 (combined) Total Vessels on active status 746 159 607 504 417 2,433 Certification I Per cent of total vessels hi district Permanent Temporary 30.7 6.5 24.9 20. 7 17.1 93 66 74 25 78 4 11 377 223 1 97 77 451 248 79 336 616 952 Total Per cent Per cent of disof total trict vessels vessels certified certified 13.0 48.4 74.3 49.2 18. 9 4.0 3.2 18.5 10.2 3.2 was both temporarily I Only the latest certificate issued on a vessel was counted in case that vessel and permanently certified during the year. INTERSTATE SANITARY DISTRICTS DISTRICT NO. 1—MAINE, NEW HAMPSHIRE, VERMONT, MASSACHUSETTS, RHODE ISLAND, CONNECTICUT, NEW YORK, N EW JERSEY, AND PENNSYLVANIA Associate Sanitary Engineer E. C. Sullivan has continued in charge of the activities of this district during the entire fiscal year. As in previous years, the work was divided into several major .classifications, differing from those of past years only in that more time was devoted to shellfish sanitation matters and that practically no rat-proofing or rodent-control work was dealt with. The major activities engaged in, and which are in general similar to those of the last few years, are as follows: 1. Supervision of drinking and culinary water supplies on vessels ,engaged in interstate traffic, including investigations of the general 108 PUBLIC HEALTH SERVICE sanitary conditions and detailed inspections of the drinking and culinary water-supply systems of such interstate carriers. 2. Supervision of drinking and culinary, water supplies used by railroad companies in interstate traffic, including investigations of the general sanitary conditions of railroad coach yards and terminals and of the methods employed in the handling of the drinking and culinary water both in the coach yards and in the coaches. 3. Cooperation with the State health departments located, within the district in the maintenance of a uniform procedure for the certification of sources of water used for drinking and culinary purposeson interstate carriers, both railroad and vessel, and cooperation in other sanitary engineering matters. 4. Cooperative activities in connection with the control of typhoid fever cases involving vessels, such as reciprocal reporting with local health departments, United States marine hospitals and quarantine stations, and the subsequent investigation of such cases when deemed advisable. 5. Cooperation in shellfish sanitation activities under the direction of the shellfish sanitation office of the Public Health Service, including surveys of shellfish-producing areas and collaboration with State shellfish-control agencies. 6. Miscellaneous activities involving matters coming within the scope of the interstate quarantine regulations, such as investigation of anthrax cases and the furnishing of information regarding interstate quarantine matters when requested. VESSEL WATER-SUPPLY SUPERVISION During the year 210 inspections of vessels were made, 67 of which had not been previously inspected. In 121 instances the vessels inspected were passenger vessels, the remainder of the inspections being of freight vessels or of water boats engaged in the delivery of water to other vessels. In these inspections the general sanitary conditions of the vessels, as well as the arrangements of the drinking and culinary water-supply systems, were covered. Improvements involving the rearrangement of the tanks, pumps, and distribution systems, so as to be independent of all other water-supply systems aboard the vessel in order to comply with the requirements of the interstate quarantine regulations, were necessary in many cases for the vessels not previously inspected. For vessels already inspected, the yearly reinspections reveal, as a rule, the necessity for minor improvements, such as the providing of new filling hose, the more sanitary maintenance of water coolers, the elimination of common drinking cups and the replacement of "Unfit to drink" signs over impure water taps, which have been lost or painted over since the last previous inspection. Experience has shown that a careful review of the vessel water supply systems is necessary each year, particularly if the piping systems of the vessel have been overhauled or rearranged, since new connections which cross-connect the drinking and culinary water supply systems to other water supply systems of the vessel may have been introduced. PUBLIC HEALTH SERVICE 109 Based upon the inspections made during the year, favorable certificates of inspection were issued for 85 vessels, 50 of which were passenger carriers and 29 were freight carriers and water boats. The cooperation with the naval architectural and shipbu'lding companies of the district in the review of the plans for the drinking and culinary water supply systems of new vessels to be constructed or under construction within the confines of the district cont.nued as in previous years. The plans for five new vessels were reviewed. Visits were made to the two shipyards engaged in the construction of these particular vessels for conferences and adjustments in the plans so as to comply more closely with the iprovis'ons of the Treasury Department circular No. 282, which is concerned with such matters. Among the vessels the designs of which were thus reviewed was the S. S. Illalolo, intended for American-Hawaiian traffic and which is understood to be the largest passenger vessel constructed in a shipyard of the United States. In accordance with the directions of the bureau, several hundred copies of reprint No. 1030 from the weekly, Public Health Reports, and concerned with the rat-proofing of vessels were mailed to naval architects, shipbuilding companies, and steamship operators located within the district. A number of requests for additional copies were received and supplied. At the suggestion of the assistant secretary of the American Society of Naval Architects and Marine Engineers, the members of the society were furnished with copies of the publication by the bureau. As in previous years, the N.ew York City health department has continued the supervision by a sanitary inspector of that department of the local excursion vessels and water boats operated in New York Harbor. The State health department of Massachusetts has cooperated in having samples of water collected from the water boats operated at the port of Boston and analyzed at the laboratory of the department. The health department of the city of Boston, Mass., has also cooperated in inspecting the sanitary conditions of the local excursion vessels which are not interstate carriers. The laboratory of the United States Marine Hospital No. 70 in New York City has likewise assisted in making bacteriological analyses of water samples obtained from trans-Atlantic vessels of the United States Lines, a subsidiary of the United States Shipping Board. Twenty-eight samples were thus analyzed. There were 51 cases of typhoid fever involving vessels having headquarters in this district reported during the year by United °States marine hospitals, United States quarantine stations, and local health departments. Of these cases, 25 were from vessels operated in interstate traffic and the remaining 26 cases came from vessels operated in foreign traffic. Table 2 indicates that the number of typhoid fever cases thus reported was less during this fiscal year than in previous years. The greatest number of cases from any one vessel was three, while four other vessels had two cases each. 110 PUBLIC HEALTH SERVICE TABLE .—Summary of vessel water supply supervision Inspections: . First inspections— Passenger Freight Total 36 31 67 Reinspections— Passenger Freight 85 58 Total 143 Certificates issued: Regular, favorable— Passenger Freight Regular,• unfavorable 56 29 0 Total 85 Major conferences: With shipping officials With others 22 -- 29. Total Water analyses made— At United States Public Health Service laboratories_ 28 7 At other laboratories -Total 35 TABLE 2.—Summary of typhoid fever eases Fiscal year 1923 Cases reported by United States marine hospitals and quarantine stations • Cases reported by local health departments Cases in which conditions on vessel were investigated Cases involving passengers Cases involving crew Foreign-owned vessels involved American-owned vessels involved United States Shipping Board vessels involved Other Government-owned vessels involved Cases involving vessels operating in interstate traffic Cases involving vessels operating in foreign traffic Vessels having more than one case Average number of cases per vessel 1924 1925 47 55 30 28 33 30 14 16 59 67 21 20 28 36 5 5 6 3 18 17 35 49 6 5 1.33 '1.24 84 27 20 14 97 22 72 •5 5 28 57 15 1.18 1926 30 21 6 6 45 14 25 3 0 25 26 5 1.13 RAILROAD WATER SUPPLY SUPERVISION Detailed inspections were made during the year of the sanitary conditions of various railroad yards and of the methods employed in the handling of the drinking and culinary water supplied to the coaches. Among the railroad yards thus inspected were those of the Philadelphia & Reading Railroad and of the Pennsylvania Railroad 6 at Philadelphia, Pa. those of the Central Railroad of New Jersey, the Pennsylvania Railroad, and the Erie Railroad at Jersey City, N. J.• and those of the Boston & Albany Railroad and New York, New Haven & Hartford Railroad Co. at Boston, Mass. As the consequence of these inspections, improvements, and the correction of various existing conditions such as more adequate precautions in the handling of filling hose, rearrangement of yard hydrants, more efficient handling of the drinking water and coolers, and more systematic sanitation of the yards were taken up with the operating officials. Observations of water coolers were made, wherever possible, to ascertain if the railroad company concerned was complying with the PUBLIC HEALTH SERVICE 111 requirements of interstate quarantine regulations now in effect forthe complete separation of the drinking water and of the ice used for cooling purposes. In one instance the matter of the removal of obsolete coolers still present in the coaches but no longer used was taken up with the operating company concerned. Conferences have been had at various times during the year with a number of the officials of State health departments located within the district relative to matters affecting the certification of sources of water supply used for drinking and culinary purposes by interstate carriers. TABLE 3.—summary of railroad water-supply supervision, Inspections: Sources of water supply Coach yards Majorconferences: With railroad officials With others (principally health authorities) 12 10 7 SHELLFISH SANITATION In September and October,. 1925, Associate Sanitary Engineer Frank R. Shaw and the district engineer made a survey of the coastal region of the State of Maine,involving about 1,200 miles of travel by automobile along the coast, in connection with shellfish sanitation activities. Based upon the survey, an extensive report covering the data obtained was prepared and transmitted to the Public Health Service office of shellfish sanitation. The data collected included information as to the general sanitary condition of the clam-producing areas of that State the conditions under which the product was prepared for shipment, the amount of interstate shipments, and other pertinent facts. Charts showing the clam-producing areas were likewise prepared. From February, 1926, to the close of the fiscal year the district engineer served as representative of the office of shellfish sanitation for matters affecting the State of New York. In that capacity a number of conferences were had with officials of the New York State Conservation Commission regarding the shellfish-control work in the State so that it might be carried out in uniformity with similar work ng of other shellfish-producing States. Inspections of shellfish-handli plants were made in some instances and approval of interstate shipments by dealers certified to by the State was made when warranted by the sanitary precautions taken in the handling of the product by the dealers concerned. the . Assistance was also rendered at various times during the year insubrily tempora r enginee district the by work on shellfish sanitati stituting for two of the sanitary engineers regularly attached to the shellfish work when detached from their stations for short periods of time. MISCELLANEOUS ACTIVITIES • An investigation was made early in September, 1925, of a case of anthrax involving a resident of Massachusetts who died in California, having had the first symptoms of the disease while en route from his native State. Due to the length of time elapsing, it was not definitely -, 112 PUBLIC HEALTH SERVICE possible to trace the cause;but considerable significance was attached to the probable use by the decedent of a shaving brush purchased with an army kit bag in 1918, but which had not been used until taken with the kit on the western trip. At the request of the field agent of the Public Health Service assigned to the Cape Cod health district a visit was made to that district late in November, 1925, to confer with local officials on sewage, garbage, and refuse-disposal problems. Arrangements were made during the year for the furnishing by chlorination apparatus manufacturers of typical water-supply chlorination apparatus to be exhibited at the sesquicentennial in Philadelphia during a portion of the next fiscal year. Among the meetings attended during the year while in, the vicinity in connection with official work were those of the American Society of Civil Engineers, American Health Congress, American Water Works Association, and the Conference of State Sanitary Engineers. At these meetings an opportunity was afforded to conveniently take up various matters with public-health officials and workers who were present. DISTRICT NO. 2.-DELAWARE, MARYLAND, VIRGINIA, WEST VIRGINIA, DISTRICT OF COLUMBIA, NORTH CAROLINA!, SOUTH'CAROLINA, GEORGIA, AND FLORIDA During the entire year this district was in charge of Associate Sanitary Engineer A. P. Miller. The activities of this district naturally fall into four major classifications: (1) Administrative duties relative to the sanitary engineering work of the domestic quarantine division; (2) inspection and supervision of water-supply systems, storage facilities, and all other water and sanitary appurtenances on interstate carriers within the jurisdiction of the district; (3) cooperation with State health departments in so far as certification of water supplies used by common carriers is concerned, and upon request in special investigations; (4) correlating and abstracting material for the Public Health Engineer- • ing Abstracts, together with a dissemination of other public-health literature among public-health workers. VESSEL WATER-SUPPLY SUPERVISION More attention has been given to the procurement and review of plans of vessels which are intended for interstate service in order to avoid the necessity of making changes in these vessels to obtain conformance with the interstate quarantine regulations after the vessels have been completed and launched. During the year this district has reviewed and approved, after slight changes, plans for five vessels. Cooperation with city health departments in the collection and. analyses of samples of water taken from interstate carriers has been continued, but the results obtained have not been as complete as could be desired. Samples collected and analyzed by the various cities are as follows: Baltimore, Md. 47; Wilmington, N. C., 27; Wilmington, Del., 10; Washington, D. ' C., 3. 113: PUBLIC HEALTH SERVICE Six cases of typhoid fever were reported in this district during the year as having occurred on vessels within its jurisdiction. Three of these which were reported as having occurred on the same United States Engineering Department dredge later were found not to be typhoid, but an investigation of conditions on this dredge was made and recommendations as to needed improvements were submitted. At the close of the fiscal year there were found to be active 65' vessel companies owning a total of 168 vessels. This shows an average of a little less than 2.6 vessels per company. The employment of an inspector for a period of two months during the summer has, been of great assistance, because it was possible for that inspector to give full time to the inspection of vessels. As can be seen in the following summary, 107 inspections were made, of which 47 were first inspections of vessels on which no inspection had theretofore been made. The percentage of first inspections is, therefore, 44, a figure which never before has been reached in this district. It is to, be expected that this large number of first inspections would call forth the issuance of a larger number of noncompliance notices for slight infractions of the Interstate Quarantine Regulations. Twenty-one notices of this nature were delivered to vessel captains, during the year. Summary of activities during fiscal year 1926 Activity Passenger Freight 5 5 7 2 35 53 2 5 0 2 6 0 55 0 Inspection: First inspection Reinspection Certificates issued: Temporary Regular (favorable) Regular (unfavorable) Both RAILROAD WATER-SUPPLY SUPERVISION The States in this district, excepting South Carolina, have all wellorganized bureaus carrying on their respective sanitary engineering duties. South Carolina has a sanitary engineer, but the efficiency of the engineering bureau is questionable. The district engineer visited every State in the district and assisted in making inspections of certain questionable water supplies. MISCELLANEOUS Transactions of the 1925 conference of State Sanitary Engineers were published during the year and, as in the past, the district engineer served as secretary-treasurer of this organization. Public Health Engineering Abstracts were issued throughout the year, and it is to be noted that material was more readily available this year than last. The table following gives pertinent data relative to these abstracts. 114 PUBLIC HEALTH SERVICE Public Health Engineering Abstracts Fiscal year ended June 30- Publications available Abstractors Weekly issues Articles abstracted Person—issues Mailing list 1922 1923 1924 1925 243 28 52 611 12,142 283 260 42 53 743 17,383 405 169 72 51 976 22,672 497 132 81 50 618 23,486 490 1926 92 79 52 542 25,532 491 In addition to the abstracts, 2,002 copies of 67 different publications and pamphlets were obtained and distributed among sanitary engineers of the States and of the Public Health Service. DISTRICT NO. 3—OHIO, INDIANA, ILLINOIS, WISCONSIN, MICHIGAN, IOWA, MINNESOTA, NORTH DAKOTA, SOUTH DAKOTA, AND NEBRASKA Associate Sanitary Engineer Joel I. Connolly was in charge of •this district up to February 26, 1926, when Associate Sanitary Engineer Isador W. Mendelsohn was placed in charge. The activities of this office have included: (1) Supervision of quality of drinking, cooking, and ablutionary water supplies and systems and general •sanitary conditions on Great Lakes vessels and trains engaged in interstate traffic (2) assistance to State health departments in establishing and improving local health service (3) special activities. VESSEL WATER SUPPLY AND SANITATION SUPERVISION Vessels under the supervision of this district are those of American :and foreign registry plying on the Great Lakes and St. Lawrence River. There are 30 American companies, with 83 passenger ships, 93 American companies, with 491 freight ships, and 2 foreign companies, with 11 freight ships now under this supervision. All of ' were inspected during the year, and the principal passenger vessels most of the freight vessels. Lack of personnel prevented inspection of all the vessels. Most of the vessels use lake water treated aboard for drinking and culinary purposes. It is necessary, therefore, that a close supervision be maintained over the operation of water-treatment apparatus aboard and the purity of the water. This is accomplished by inspections by service engineers and laboratory analyses made through the cooperation of the State health departments of New York, Ohio, Illinois, Michigan, ,Wisconsin, and Minnesota, and by the city health department laboratories of Buffalo, Rochester, Sandusky, Toledo Cleveland, Detroit, Chicago, and Milwaukee. The Provincial Department of Health laboratory of Sault Ste. Marie, Ontario, through the Canadian Federal health department has furnished valuable assistance by analyzing samples of water from the freight vessels passing through the locks. The Toledo health department has also made analyses of water from freight vessels. This cooperative laboratory work has led to discontinuance of raw lake water for drinking and culinary purposes on some im- PUBLIC HEALTH SERVICE 115 portant passenger vessels and many freighters and is impressing the vessel engineers with the need for careful and conscientious treatment of the water. In the supervision of water supplies and systems and general sanitation aboard vessels the following points have been stressed: (1) Satisfactory treatment of lake water at all times where such water is used for drinking and culinary purposes, and also use of approved city water where polluted water, as in the Detroit River, is used for ablutionary purposes; (2) adequate sanitary storage tanks for pure water; (3) removal of all toilet outlets forward of seacock furnishing lake water for drinking and culinary purposes; (4) removal of raw lake-water taps at galley sinks; (5) removal of ,common towels and glasses; (6) prevention of use of untreated lake water in firehold for drinking; (7) sanitary condition of food storage places; (8) elimination of all cross , connections between impure-water systems and the pure-water system; (9) painting or marking all pure-water lines light blue; (10) posting of water supply system certificates. The cooperative arrangement with the Canadian Federal Department of Health has been maintained during the year and has resulted in interchange of information of vessel movements water supplies, and sanitary conditions, laboratory analyses, typhoid-fever eases among Great Lakes seamen, and procedures regarding the supervision of vessels. Other agencies cooperating with this office were (1) the United States engineer's office at Sault Ste. Marie, Mich, which provided office space and facilities to the inspector of this district stationed at that place; (2) the inspectors of the Steamboat Inspection Service at Great Lakes ports, who furnished data of vessels; (3) the Lake Carriers' Association, which assisted in informing the freight companies regarding sanitary conditions aboard vessels and obtaining satisfactory improvements. A number of Norwegian vessels coming with cargoes directly from Europe to Great Lakes ports and then operating between Canadian and American ports were inspected in accordance with the procedure stated in last year's annual report, page 101. During the year there were 10 cases of typhoid fever among Great Lakes seamen reported by the marine hospitals. The occupations of these were as follows: 5 firemen, 2 deckhands, 1 wheelsman, 1 oiler, 1 watchman. The following table summarizes the typhoidfever cases among Great Lakes • seamen hospitalized at United States marine hospitals since 1915: Navigation season 1915 1916 1917 1918 1919 1920 Navigation Cases 60 70 49 39 24 20 1921 1922 1923 1924 1925 1926 Cases 13 17 25 21 7 10 Inspector H. M. Whimster was employed at Sault Ste. Marie, Mich., from July 1 to November 1, 1925, and May 1 to June 30, 1926. In these periods he inspected 297 freight vessels, reinspected 33, and collected the samples of water for analysis by the provincial health 116 PUBLIC HEALTH SERVICE department laboratory at Sault Ste. Marie, Ontario. He also prepared drawings of the pure-water systems aboard many of these vessels and made an investigation of a typhoid-fever case aboard the lighthouse tender Aspen aCCedarville, Mich. Plans of four new vessels under construction at shipyards were reviewed in regard to satisfactory pure-water systems. Assistance has been rendered the Chicago health department in the proper installation and operation of sewage-retention tanks aboard vessels docking at Chicago to prevent pollution of bathing beaches and the lake near the water-intake cribs. A special effort is being made in cooperation with vessel companies and employment agencies to have all food handlers aboard Great Lakes vessels examined physically and those found with communicable diseases dismissed. It is expected that this work will be completed by August 1, 1926. It is the policy of this office not to prepare regular certificates for vessel water systems until sufficient data are available regarding the proper treatment of the water aboard. For this reason the number of such certificates issued in the past year is small. It is believed data will be available early in the coming year which will permit issuance of a _large number of regular certificates. Summary of vessel water-supply supervision Inspections: First inspections— Passenger Freight Reinspections— Passenger Freight Docks Certificates issued: Temporary— Passenger Freight 54 306 9 35 12 43 350 Certificates issued—Continued. Regular, favorable— Passenger Freight Regular, unfavorable Major conferences: With shipping officials With others Water analyses made at— City laboratories Canadian laboratories 73 0 48 52 928 795 Conferences were held with manufacturers of water-treatment apparatus used aboard Great Lakes vessels regarding their design and operation, and arrangements were made for improved servicing of the machines. COOPERATION WITH STATE HEALTH DEPARTMENTS AND RAILROAD WATER-SUPPLY SUPERVISION Conferences were held with State health officers or sanitary engineers of States in this district in regard to improving the certification of railroad water supplies. A distinct improvement in many States is expected. Assistance was rendered the State health departments of Iowa, Minnesota, Indiana, Wisconsin, and Illinois in regard to streampollution problems affecting them. On behalf of the State board of health, an inspection was made of the public water supply of Deadwood, S. Dak., used by railroads. Assistance was rendered the State board of health of North Dakota by making an investigation of the effect upon public health of a proposed dam across the Red River of the North at Grand Forks, N. Dak. PUBLIC HEALTH SERVICE 117 Assistance was rendered the joint committee on drinking-water supplies of the American Railway Association in endeavoring to have a report on coach yard sanitation adopted as railway standard practice. The district engineer attended the annual meeting of the American Railway Engineering Association to consider the report of the water-supply section. Inspections were made of coach yards in Chicago in regard to sanitary conditions and facilities for watering and cleaning cars. SPECIAL ACTIVITIES The following special activities were carried out during the year in this district: (1) Investigation of the well-water supply of United States Veterans' Hospital, Edward Hines, jr., at Maywood, Ill., which was not completed on July 1; (2) data regarding the supplying and handling of milk on dining cars and vessels of several companies in this district were collected; (3) three papers were prepared, one for Public Health Reports, and two for The Nation's Health; (4) a brief account of the work of this office was prepared for a newspaper. DISTRICT 4-ALABAMA, MISSISSIPPI, MISSOURI, LOUISIANA, OKLAHOMA, ARKANSAS, KANSAS, KENTUCKY, TENNESSEE, AND TEXAS • Associate Sanitary Engineer A. L. Dopmeyer continued in charge of this district during the fiscal year. The activities of the district may be grouped under the following headings: (1) Supervision over water supplies used for drinking and culinary purposes on vessels; (2) Supervision over water supplies used for drinking and culinary purposes on railroad trains; (3) Cooperation with State health departments; (4) Special investigations, lectures, reports, etc. VESSEL WATER-SUPPLY SUPERVISION As last year, it was found impossible, on account of lack of time and personnel, to make the necessary inspections and to issue certificates for all vessels operating in the district. Particularly was this true of vessels operating out of ports on the Gulf of Mexico, so distantly removed from St. Louis as to admit of only infrequent visits. A recircularization of vessel companies during the year resulted in placing in the active files the names of 209 vessel companies, operating a total of 515 vessels. These figures are for carriers actively .engaged in interstate traffic, and do not include vessels owned by the United States Government. The policy of maintaining a constant record of the quality of water used on the more important passenger and excursion vessels, by obtaining bacteriological analyses from city and State authorities, was continued and was augmented somewhat. A total of 1,261 reports of the results of analyses of samples of water, collected and analyzed by the following agencies, were received during the year: (1) City health department, Cincinnati, Ohio; (2) city health department, Louisville, Ky.; (3) United States Public Health Service relief station, Paducah, Ky. (samples analyzed at State laboratory, Louis- 118 PUBLIC HEALTH SERVICE vile, Ky.); (4) city health department, St. Louis, Mo.; (5) cityhealth department, Memphis, Tenn.; (6) State board of health,. New Orleans, La. (samples analyzed in joint city and State laboratory); (7) city health department, Mobile, Ala. (samples analyzed in State branch laboratory at Mobile). Samples of water were also collected by the district engineer during inspection trips from points in the States of Mississippi,. Tennessee, and Arkansas, and were analyzed in the respective State boards of health laboratories. The reports of bacteriological analyses received have been of great value in maintaining a control over the water supplies ,on many vessels carrying large numbers of passengers, a result which could have been obtained in probably no other way except by frequent personal inspections. In several cases, sickness in members of crews has been reported almost concurrently with reports of unsatisfactory analyses. In each case where bacteriological reports indicated an unsafe water supply on a vessel, instructions were immediately forwarded for sterlizing the water-supply system, and a personal inspection was made at the earliest opportunity. During the year, reports were received from marine hospitals and relief stations of 28 cases of typhoid fever in seamen. The increased number over the last year may be attributed to the inclusion in this district of supervision over vessels operating on the Gulf of Mexico. An analysis of these reports shows that 11 are for persons who had been employed on vessels operating on the Gulf of Mexico, while 17 had been on river vessels. This shows a decided decrease in the rate for river vessels over the last year, and although there is no, record on hand for cases reported from vessels operating on the Gulf. of Mexico during the last year, the number reported this year seems to be very small in view of our limited opportunities to control conditions on these vessels. Of the typhoid fever cases reported in connection with river vessels, but eight were for persons who had been employed on vessels owned by the United States Government, showing a proportionate decrease in the number of such cases over those of last year. Upon receipt of a report of a case of typhoid fever, the vesseloperating company was immediately notified and instructions were issue,d for sterilizing the water-supply system and for making an inspection of the vessel. This action was followed by a personal inspection as time and opportunity permitted. In some cases it wasfound that living conditions of the patient ashore were insanitary, whereas conditions on the vessel were apparently satisfactory, and that the patient had been living ashore a large part of the time. The inspection of water-supply systems on Government-owned vessels were made only upon request of the officials in charge. In case typhoid fever reports were received for persons employed on such vessels, however, the responsible official was notified and recommendations were made for averting further possible sickness. In one such case where an investigation of the sickness of two persons indicated that it was probably the result of admittedly insanitary con-. ditiOns on a vessel of the Mississippi River Commission, the matter was taken up with the president of the commission, and general rec- PUBLIC HEALTH SERVICE 119 ommendations for improvements were made for all district engineers serving under the commission. Conferences were held at various times during the year with officials in charge of the operation of Government-owned vessels, including those of the War Department, Lighthouse Service, Mississippi River Commission, and the Goltra Barge Line. A decided increase in the interest of such officials in improving the water supply and. sanitary conditions on the vessels under their' charge has been noted, and there has been a noticeable improvement in the actual conditions on the vessels. *It has been the policy to recommend to officials of vessel companies the use of certified city-water supplies, wherever possible, in preference to using an apparatus on the vessel for rendering a polluted overboard supply safe and suitable for drinking and culinary purposes. It has been found particularly difficult to obtain an economical and efficient purification apparatus that will accomplish the desired end when used on steamboats operating in certain sections of the Mississippi and Ohio Rivers, where these rivers are heavily polluted and very turbid. There are a large ilumber of vessels, such as towboats, however, on which it would be inconvenient and impracticable to obtain water trom city supplies on account of the irregularity of their schedules. On such vessels recommendations were made to purify the water aboard in preference to attempting the carrying of an adequate supply of city water. On account of the various makes of water-purification apparatus on the market, the designs of which render them unsuitable for use on steamboats, although otherwise probably satisfactory, it has been the policy in this district to keep the officials of vessel companies informed of certain requirements in this connection. As a result installations of unsatisfactory apparatus were found in only two cases during the year. In one of these cases the apparatus has since been abandoned and in the other it was found to have been purchased without due authority from the company, and has been rendered satisfactory by costly reconstruction. The distilling plant continues to be the most satisfactory apparatus in general for purifying water aboard on steamboats. On 113 vessels of the 515 in the active list the water is purified aboard—in 111 cases by the process of distillation and in 2 cases by filtration followed with ozone treatment. There are now six companies manufacturing commercial purification apparatus the products of which are being used with satisfaction on river vessels. In two of these cases the products of the companies are modified designs resulting from recommendations made by the district engineer and personal conferences with officials of the companies during the year. Shipbuilding companies and companies planning the construction of new vessels have been informed concerning the proper design of the water-supply system. The Steamboat Inspection Service has rendered a valuable service during the year by submitting certain data in .connection with the water supply on vessels obtained at the time of its inspection. 120 PUBLIC HEALTH SERVICE Summary of vessel water-supply supervision Inspections: First inspections Reinspections 'Certificates issued: Temporary Regular,favorable Regular, unfavorable 16 108 71 23 0 Major conferences: With shipping officials Other Water analyses made: State laboratories City laboratories 72 6 65 1,196 RAILROAD WATER-SUPPLY SUPERVISION The supervision over water supplies used by railroads in interstate traffic consisted in making surveys of provisions in coach yards for watering cars, in investigating the water-supply equipment and its condition on trains, and in having unsatisfactory designs of water coolers corrected. Surveys of coach yards were made, as opportunity permitted, at St. Louis, Mo.; Texarkana, Tex.-Ark.; Galveston, Tex.; New Orleans, La.; Montgomery, Ala.; Birmingham, Ala.; Nashville, Tenn.; and Louisville, Ky. In cases where water-supply systems on trains were found to be unsatisfactory due to neglect or carelessness, the matter was called to the attention of the responsible local officials. The unsatisfactory design of a water cooler has, in one instance, been corrected by taking the matter up with officials of the manufacturing company. COOPERATION WITH STATES On account of lack of sufficient funds and personnel in the health departments of some of the States in this district adequately to carry out the work of certifying water supplies used by interstate carriers, assistance was rendered where it was believed to be most necessary. Accordingly, surveys of interstate-carrier water supplies were made at the request of, and reports submitted to, the respective State boards of health, as follows: State Number of water supplies surveyed Oklahoma Arkansas Texas Louisiana Tennessee Kentucky 30 14 8 2 2 2 MISCELLANEOUS At the request of the State board of health of Texas, a paper was prepared for presentation at its school for filter plant operators, held at Fort Worth in January. A paper was also .prepared and delivered before a gathering of waterworks officials of Oklahoma at the Agricultural and Mechanical College in Stillwater in March. Meetings of a scientific nature held at places in this district during the year were attended as opportunity permitted. PUBLIC HEALTH SERVICE 121 Abstracts of 21 articles were prepared for publication in the Public Health Engineering Abstracts. DISTRICT 5.—ARIZONA, CALIFORNIA, COLORADO, NEW MEXICO, NEVADA, AND UTAH DISTRICT 6.—IDAHO, MONTANA, OREGON, WASHINGTON, AND WYOMING Sanitary Engineer H. B. Hommon continued in charge of interstate sanitary districts 5 and 6 and supervision over sanitation in national parks. He was also placed in charge of shellfish district No. 7 during the year. He was assisted by Associate Sanitary Engineer I. W.Mendelsohn,up to February 20,1926,Associate Sanitary Engineer F. R. Shaw, after May 19, 1926, and Assistant Sanitary Engineer L. D. Mars, for the entire year. The work carried out during the year was divided as follows: (1) Examination of water-supply systems on vessels engaged in interstate traffic; (2) cooperation with the State departments of health in the two districts in the examination of water supplies used on trains operated in interstate traffic and in the investigation of special problems of sanitation; (3) cooperation with the National Park Service in improving sanitation in the national parks; (4) shellfish sanitation. VESSEL WATER-SUPPLY SUPERVISION The inspection of vessel water-supply systems was carried out by one engineer over a period of nine and one-half months. There are approximately 450 vessels divided among approximately 125 companies engaged in interstate traffic in the two districts. While most of the vessels can be inspected in Seattle, Portland, San Francisco, and Los Angeles and adjacent ports, there are large numbers on the rivers that do not come to the coast ports. The territory to be covered, therefore, embraces a coast line 1,400 miles long and rivers aggregating several hundred miles in length. An attempt has been made, however, to inspect all the passenger-carrying vessels, including ferries and all the large freight boats, and it is believed that more than 90 per cent of the passengers and seamen cariied on vessels engaged in interstate traffic in districts 5 and 6 used water from vessels with approved water-supply systems. TABLE 1.—Summary of vessel water-supply supervision (Calendar year 1925) Inspections: First inspections— Passenger Freight Reinspections— Passenger Freight Certificates issued: Temporary— Passenger Freight Regular— Passenger Freight 14656-26-9 45 18 115 321 0 0 85 24 Typhoid fever cases: Reported by marine hospitals (Three cases on 1 boat, all others on different vessels.) Investigations made Major conferences: With shipping officials 8 1 11 122 PUBLIC HEALTH SERVICE RAILROAD WATER-SUPPLY SUPERVISION A complete survey' was made of all the water coolers in use on Pullman cars and coaches on all the railroads entering San Francisco, Oakland, and other San Francisco Bay cities, and a survey was made of the coolers on Pullmans and coaches of the Denver & Rio Grande Railway Co. at Denver. Practically all coolers were found to comply with the interstate quarantine regulations regarding the separation of ice and filling arrangements. COOPERATION WITH STATES The work carried out in cooperation with the State health departments of the 11 States in the two districts followed the general lines of previous years. In Idaho a service engineer, working- in conjunction with the State sanitary engineer, made a survey of 39 municipal and 13 railroad water supplies and investigated various problems of sanitation in the State. Conferences were held with the State health officer of Montana in regard to certification of water supplies in the State used on interstate carriers, and with the State health officer of Utah in regard to the cause of taste and odors in the Salt Lake City water supply. In Oregon, Washington, Arizona, Nevada, Wyoming, and California, problems of water supply, sewage, and garbage disposal have been considered with representatives of the respective State boards of health. In cooperation with the State health officer of Oregon, an investigation was made of the pollution of the Willamette River at Portland, and conferences were held with the city authorities of Portland and the cities and towns on the Willamette River above Portland, in regard to methods for examining the river water to determine the extent of pollution. In connection with this work a deep-water sampling device for taking dissolved oxygen and bacteriological samples at 35 to 40 feet depths was designed by service engineers. In compliance with a request from the United States Forest Service, an investigation was made of the sanitary significance of stock grazing on the watershed of the Walla Walla, Wash., municipal water supply, which is obtained from Mill Creek watershed, lying within the Umatilla National Forest. The report of the investigation is to be used by the Forest Service as a guide in deciding future controversies involving the dual use of watersheds of the national forests for grazing and sources of public water supplies. A paper on the United States Public Health .Service and Municipal Water Supplies" was read before a conference of waterworks superintendents of Colorado, Wyoming, and New Mexico, and assistance was given to the State sanitary engineer of Montana and the director of the State hygienic laboratory of Nevada in the preparation of papers on the water supplies of Montana and Nevada. SANITATION AND MEDICAL ASSISTANCE IN THE NATIONAL PARKS The assistance rendered the National Park Service, at the request of the Secretary of the Interior, in maintaining proper sanitary conditions in the national parks was continued during the year on a broader and larger scale than in previous years. Associate Sam- PUBLIC HEALTH SERVICE 123 tary Engineer Isador W. Mendelsohn was assigned to Yellowstone Park from June 1 to September 25, 1925, to look after water supplies, sewage and garbage disposal, mosquito control, and camp sanitation. Associate Sanitary Engineer Frank R. Shaw was detailed to the Grand Canyon National Park on May 19, 1926, to start the new activated sewage-freatment plant in operation and to continue in charge until a chemical and bacteriological laboratory is equipped plant is established. and in operation and routine operation Acting Asst. Surg. N. A. Strickland was on duty during the park season of 1925, and L. J. Stauffer during 1926. The work carried out by the acting assistant surgeons consisted of inspections of hotels, barber shops, mess houses, and other places handling and selling food products and soft drinks. The more important activities carried out in the various parks during the year were as follows: Yellowstone.—New construction work included the design and installation of sewerage systems and treatment plants for Camp Roosevelt, West Thumb, and the Transportation Co. headquarters at the Gardiner entrance, and a new water supply at West Thumb. Particular attention was given to the operation of the 10 sewagetreatment plants constructed during the past few years. The effluents of six of the plants are sterilized with liquid chlorine to protect the streams from contamination. As a check on the efficiency of the sterilization, samples of effluents and streams were collected at intervals of about 10 days and sent to the laboratory of the Montana State Board of Health for analysis. The State board of health continued, as in the past, to make the analyses without cost to the Government except express charges. Daily readings of the amount of chlorine added to the effluent from each plant were made and qualitative and quantitative tests made and recorded for the amount of chlorine added. At four of the sewage-disposal plants the effluents are discharged onto natural beds of sand or gravel protected by concrete walls and top. A special design of housing over the natural filter beds has been worked out, so that the solids are retained in the inlet section and the supernatant fluid flows to succeeding sections. The data obtained from the analysis of samples of water from streams receiving sterilized sewage effluents and from streams adjacent to the natural filter beds show that the sewage from all the treatment processes is being handled in a manner that does not contaminate the streams. A complete survey was made of all the water supplies used for domestic purposes, and where there was any suspicion regarding contamination samples were sent to the Montana State Board of Health for analysis. All supplies in the park were found to be of a high degree of purity. The cold-water supply used for the bathing pool at the Upper Basin has not been satisfactory for two years. A new source was located and recommendations were made that it be developed and installed during the present year. A decided improvement was made in the methods of disposing of garbage in the park during the year, but the solution of the garbage-disposal problem will riot be reached until incinerators similar to those in use at Seq aoia, Yosemite, and Grand Canyon are installed. 124 PUBLIC HEALTH SERVICE Mosquito-control work was carried out during the year along the same general lines as in previous years. Each spring infested pools are oiled, and in the fall all available funds are used for draining the areas where larvae were found in the spring. Practically 90 per cent of the areas within three-fourths of a mile of the principal junctions have been drained. The mosquito euisance has been materially reduced, but it can never be entirely relieved, owing to the fact that there are large numbers of saddle and pack horses and bears traveling back and forth from forests to hotels and camps, and these animals bring mosquitoes with them in large numbers. Yosonite.—The most notable achievement in the Yosemite Park during the year, from the standpoint of sanitation, was the completion of the garbage incinerator and the installation of a cancrushing machine to mash waste tin cans, and a garbage-can washing equipment to wash empty garbage cans. The waste tin cans are crushed into bales weighing about 200 pounds and are not burned in the incinerator. Their volume is reduced about 92 per cent. The hot water for washing the garbage cans is obtained from hot-water pipes in the incinerator used as bearing bars for the drying grates. There is no nuisance from odors or flies around the plant, and the cost of operation during the peak of the season is approximately $12 per day less than the old method of disposing of the garbage by burning in windrows on the ground. By locating the incinerator near the headquarters, the cost of handling garbage has been practically reduced by one-half. All the equipment used in connection with the disposal of garbage was designed by Public Health Service engineers, except the cancrushing machine which was recommended by service engineers. This equipment is probably more complete than any other ever used in handling a garbage-disposal problem. Other activities in the park included cooperation with the civil engineer of the park in the operation of the sewage-disposal plant, location of and design of sewage-disposal plants for Tuolumne Meadows and Hetch Hetchy Dam developments, and general supervision over work connected with sampling and analyzing samples of water from Merced River below sewage-treatment plant. Grand Canyon.—During the year a sewerage system, consisting of 5 miles of vitrified pipe and two long siphons for domestic sewage, and 1 mile of vitrified pipe for laundry wastes, were installed, and a sewage-treatment plant was constructed, which consists of presettling tank, activated sludge tank, Dorr clarifier, coagulation tank, rapid sand filters, and sterilization equipment. The treatment plant was placed in operation on May 29, 1926, and although there were some operating difficulties at first, the effluent was clear and stable and entirely satisfactory. The effluent is now being used for boiler purposes, irrigation, cooling water for Diesel engines, and later will be used for flushing toilets in restricted places. The distribution pipes for the reclaimed sewage will be inclosed in vitrified pipes, the outlets will be painted red, and posted, and the pressure on the reclaimed sewage pipes will be less than that in the fresh-water lines. A garbage incinerator was designed for the Canyon, and on June .30, 1926, it was about one-half completed. It is of the same design PUBLIC HEALTH SERVICE 125 as the one built in Yosemite, except for a few changes that seemed advisable in order to secure longer life for the drying grates. The can-crushing machine and garbage-can washing equipment are similar to those in use at Yosemite. The garbage incinerator and other equipment, and the sewerage system and sewage-treatment plant were designed by Public Health Service engineers working in cooperation with Park Service and Santa Fe Railway engineers. Other activities in the park included general inspections of camp grounds and all places handling or selling food products or soft drinks. Glacier.—The work in Glacier included the regular routine inspections of hotels, camps, stores etc., and recommendations for genera,1 improvements in methods of disposing of sewage and garbage and for a better water supply at one of the hotels. Mt. Rainier.—General inspections were made and recommendations given for a new water supply for Longmire and better methods of sewage and garbage disposal for Paradise Valley 'automobile camp. Crater Lake.—During the year a new sewerage system and disposal plant were constructed from plans'prepared by Public Health Service engineers. Other work carried out in the park consisted of general routine inspections and recommendations for developing, storing, and pumping an adequate water supply for the park. Recommendations were also made for a modified chemical toilet for the boat landing at the lake. Sequoia and General Grant.—General inspections of sanitary conditions were made during the year and a careful survey was made of the new water supply and sewerage systems and disposal plants in the two parks, and the garbage incinerator at Sequoia. These utilities were installed during the last few years from plans furnished by service engineers, and they were found operating in a very satisfactory manner. A suitable form of small trash burner was recommended for the automobile camps and it is becoming.generally adapted in the national parks. Mesa Verde.—Estimates were prepared for the cost of installing new water supply and sewerage systems and disposal plant. In addition a routine general inspection was made in the park. Zion National Park.—As a result of recommendations made, storage and refrigeratiQn facilities were greatly enlarged at the Lodge, and the equipment for sterilizing the sewage from the Lodge was replaced by more efficient apparatus and the filter galleries were increased by more than 100 per cent. At the Government automobile camp a new filter gallery further removed from the Virgin River was constructed. Platt.—Up to this year no inspection had been made in this park by service engineers. Owing to the fact that the mineral springs, which constitute the main attraction of the park, are located practically at the water level of a stream that flows through the town of Sulphur, and the city sewer parallels the stream, there is a serious problem to work out in protecting the springs against contamination. There is also a sewage disposal problem to be worked out by the Government and the town of Sulphur. The State board of health of Oklahoma is cooperating and making regular analyses of samples of water from the springs. 126 PUBLIC HEALTH SERVICE Carlsbad Cave National Monument.—This cave was taken over by the Park Service during the year and a service engineer supervised the construction of emergency water supply and comfort stations in the cave and comfort station at cave entrance at surface of the ground, and made recommendations for permanent sewerage system and disposal plant at entrance. Pinnacles National Monument.—A general inspection of the Pinnacles was made and recommendations were given for improving water supply and taking care of camp grounds. Conference of park superintendents.—A service engineer attended the annual conference of park superintendents and presented a paper on the work that has been accomplished in the parks and the work that is yet to be carried out. SANITARY CONTROL OF SHELLFISH CaZifornia.—The only oysters grown in California are shipped from the East or South and planted in San Francisco and Tomales Bays. These beds were inspected by a representative of the service and the California State Board of Health. The San Francisco Bay beds have been approved by the State board of health and the certificates for Tomales Bay are being withheld pending the removal , of some potential contamination. The State board of health does not approve or disapprove shucking houses in the State. Oregon.—This State produces only a very small amount of shellfish, and practically no work has been done in connection with examination of oyster beds. Washington.—The oyster industry in Washington is by far the largest on the Pacific Coast. The native Olympia, or Pacific coast, oyster and the Japanese oyster are grown from "seed," and eastern oysters are imported and relaid on a large scale. About two-thirds of the larger growing areas and shucking houses were inspected by a service engineer and found to be in good sanitary condition. The State boar of health and the Olympia Oyster Growers' Association are cooperating in a practical and effective manner. The State board of health approves shellfish-growing areas and shucking houses. SANITARY INSPECTIONS OF SHELLFISH AREAS The active work in connection with the sanitary conditions of the shellfish industry was started at the beginning of the fiscal year, at which time the entire personnel, consisting of 2 medical officers, 4 sanitary engineers, 4 technical assistants in sanitary engineering, 1 bacteriologist, 1 pilot, 1 marine engineer, and 2 attendants, was assembled at the headquarters established at Craney Island, Va. In order that the work might be carried on uniformly throughout the shellfish-producing regions, 'seven districts were formed, as follows: Shellfish Shellfish Shellfish Shellfish Shellfish Shellfish Shellfish district No. 1, New England States. district No. 2, New York, New Jersey, and Pennsylvania. district No. 3, Delaware and Maryland. district No. 4, Virginia and North Carolina. district No. 5, South Carolina, Georgia, Florida, and Alabama. district No. 6, Mississippi, Louisiana, and Texas. district No. 7, Pacific States. PUBLIC HEALTH SERVICE 127 Each of the first six districts was placed in charge of an engineer, who began actual field work on July 15. A survey of shellfish conditions on the Pacific coast was made by Sanitary Engineer R. E. Tarbett in November, and the supervision of the work in this district was then placed under the engineer in charge of interstate sanitary district No. 5. A floating laboratory was installed on the launch Sh,earwater, in charge of a technical assistant in sanitary engineering, this laboratory cooperating with the district engineers and State authorities in examination of shellfish-growing areas. A research laboratory was installed at Craney Island. Two medical officers and one sanitary engineer devoted their time to administrative supervision of field and research activities. It was recognized that the sanitary control of the shellfish industry within the borders of a State was strictly a State function, and that the service should not attempt to regulate the industry, except in its interstate commerce aspects, unless such work was undertaken in cooperation and conjunction with the State authorities. It appeared that an important function of the Public Health Service was the promotion of reasonably uniform rules, regulations, and methods of enforcement in the various States, and work toward this end has progressed fairly satisfactorily. The service has undertaken surveys of the methods of control exercised by each of the producing States to determine their adequacy to assure a reasonably safe product. It was recommended that eaeh of the producing States issue a certificate that the shellfish produced in that State and shipped or offered for sale as food were produced and shipped in accordance with the sanitary requirements of a properly constituted State agency. If the surveys indicated that control measures were satisfactory, the State's certificate was accepted by the Public Health Service as sufficient evidence that the holder of such certificate had complied with the requirements prescribed for the shipment of shellfish in interstate commerce. Such acceptance of certificates of shippers in the various States was announced by the publication of lists of such accepted shippers, giving the name, address, and shipping number of each person or firm so certified: Arrangements were made with the Canadian Minister of Health whereby a copy of each certificate issued by producing States was furnished him through the Surgeon General, and this was accepted as sufficient to cover the certification requirements of shellfish shipped to that country by the holder of such certificate. The Public Health Service has furnished information to State and municipal health authorities as to the progress of shellfish sanitation in the various States, including a statement of opinion as to the adequacy of measures carried out and of the methods employed. The floating laboratory installed on the launch Sh,earwater has visited 12 States on the Atlantic and Gulf coasts, actually doing work of examining shellfish in certain areas. This work has done much to promote uniformity of method of bacteriological testing of shellfish in the various States and has also given the State authorities ample demonstration of the advantages of a floating laboratory as compared with a fixed laboratory on shore. The laboratory at Craney Island has assisted in the examination of routine samples whenever possible, and has carried on investiga- 128 PUBLIC HEALTH SERVICE tions on some of the fundamental problems of shellfish sanitation, such as (1) the relation of the index of pollution of shellfish to that of the water from which they are taken, (2) the comparison of different methods of laboratory examination,(3) comparative studies of the pollution of oysters and clams, (4) studies upon washing of oysters as a means of reducing bacterial contamination, (5) studies on the use of chlorinated water as a means of furthering shellfish sanitation, and (6) studies on the effect of temperature on shellfish pollution. These studies were all in progress at the end of the fiscal year, and final conclusions have not been reached. A chlorination plant has been constructed for experimental purposes and will be operated for at least a full year in order that information may be obtained at all seasons and at different temperatures. No outbreaks of typhoid fever attributable to shellfish have been reported during the year. Two small outbreaks alleged to have been due to infected oysters were investigated, but the evidence in both cases did not point to the consumption of oysters as a cause. Throughout the year the advisory committee appointed by the Surgeon General in 1925 has been of great assistance in formulating the plan of work and in recommending administrative regulations governing the shellfish industry. The work has been conducted in cooperation with the Bureau of Chemistry, Department of Agriculture, and the Bureau of Fisheries, Department of Commerce, as well as with the various State departments of health, or- other State agencies having jurisdiction over shellfish sanitation in their respective States. RURAL HEALTH WORK Cooperative demonstration projects in rural sanitation were carried out in the fiscal year ended June 30, 1926, in 89 counties, or districts comparable to counties, in 20 States, as follows: Alabama Arkansas California Georgia Illinois Iowa Kansas Kentucky Louisiana Massachusetts 9 2 3 8 1 1 4 1 2 1 Mississippi Missouri Montana New Mexico North Carolina Oklahoma South Carolina Tennessee Virginia West Virginia 3 13 2 8 1 3 1 6 12 8 The appropriation "For special studies of and demonstration work in rural sanitation," with which the cooperative rural health work of the service is conducted, was $75,000 for the fiscal year 1926. Against this was set up a budget saving of $2,000. The unexpended balance from the operations of the preceding fiscal year was $10,055.55. Thus $83,055.55 was available. The expenditures totaled about $82,875. Of this amount, about $4,800 was expended for special studies and administration, and $78,075 was expended through specific allotments for the support of the 89 field projects. Over nine-tenths of the total funds for the operation of the field projects was provided by agencies—mainly, State, county, and municipal bodies—cooperating with the service in the demonstration work. PUBLIC HEALTH SERVICE 129 The plan of the work was similar to that of the several preceding fiscal years. This demonstration work in rural sanitation is made a part of a general program of well-rounded, whole-time county health service. By dovetailing the specific sanitary activities with other salient branches of county health work, overhead expense is lessened, lost motion and friction are prevented, and lasting results are obtained. The results in the demonstration projects as a whole were highly satisfactory. Human lives were saved, human disease was prevented, human health was promoted, and economic resources amounting to many times over the cost of the service were conserved. The yield to the public welfare on the dollar invested for this work seems larger than that obtainable on the dollar which is or may be invested for any other public activity in normal times. There is critical need for more whole-time, efficient, economical health service in our rural communities, as only about 15 per cent of our rural people are yet provided with such service. The cooperation of the Public Health Service in this field of work evidently causes the development of efficient whole-time rural health departments which, without such cooperation, would not be developed. There seems no other way in which the service can do as much at equivalent cost toward meeting its responsibility to prevent the spread of human infection in interstate traffic as it can through Cooperation with State and local authorities to establish and permanently maintain efficient, whole-time local health service. Counties with efficient, whole-time health departments, receiving financial assistance from the service, furnish exceptionally favorable situations for practical research studies of the diseases of man and conditions influencing the propagation and spread thereof—the sort of studies with which the service is especially concerned. (Sec. I, act of August 14, 1912, ch. 288, 37 Stat. L. 309.) With efficient, cooperative county health service throughout the United States, large sums of money now expended by Federal and State agencies for quarantine and hospitalization could be saved, because much of the present need for these activities would no longer exist. The evidence is that without sympathetic cooperation and financial assistance from State and Federal Government agencies, satisfactory *progress in the development of efficient, whole-time rural health service in the United States within the next 25 years is not reasonably to be expected. MOSQUITO CONTROL ALONG THE TEXAS-MEXICAN BORDER During the fiscal year ended June 30, 1926, yellow-fever-control measures, instituted in 1923, were continued along the Texas-Mexican border. In previous years work was maintained not only in the strictly border areas but also in those communities within close travel of the border, since this area, composed almost entirely of farming lands with numerous roads running through it in all directions, might, under favorable conditions, harbor yellow fever. On account 14656-26----40 130 PUBLIC HEALTH SERVICE of limited personnel and funds with which to carry on the work, it was deemed best during the past year to concentrate upon strictly border areas, and operations in nonborder communities were discontinued October 1, 1925. Since that date the work has been intensified upon that part of the border extending from Laredo to Brownsville. In most of the areas in which work has been undertaken local cooperation has been good, the various communities as a rule recognizing its importance, assisting in every way possible and enforcing regulations which would aid in mosquito control. Clean-up campaigns were inaugurated in many towns. The methods employed have been practically the same as in previous years, stressing education of the public and cooperation with property owners for mosquito control. Weekly inspections were made in those communities where there was local cooperation. In other communities service employees made such routine inspections as were possible, the period between such inspections depending upon the activity of the local community. During the year work was conducted in nine counties, although this number was reduced to four October 1, 1925, when work was discontinued in nonborder communities. There were 817,190 inspections of premises, 67,223 inspections of water barrels, 39,464 inspections of cisterns (including wells, tanks, etc.), and 1,910,240 inspections of other containers, making a total of 2,016,928 inspections made by service employees alone. In addition, a large number of inspections were made by local officials. The number of water barrels was reduced over 50 per cent. In the city of Brownsville alone the number was cut from 1,400 to less than 400. No dengue fever has been reported on the border during the year, nor have there been any cases of yellow fever. In view of the fact that yellow fever no longer threatens from Mexico, the bureau, under date of March 10, 1926, directed the discontinuance of this work at the close of the fiscal year. The municipalities and communities along the border were advised in ample time of the action contemplated in order that they might arrange for local continuance of mosquito-control measures. It is believed that the effect of the work done will be permanent, inasmuch as towns which heretofore paid no attention to water barrels and other containers where mosquito breeding was prevalent • have reduced these to a minimum. Many cisterns have been filled or done away with entirely since the inauguration of the work. On July 1, 1925, the personnel engaged upon this work consisted of three general sanitary inspectors, three furnishing their own auto transportation, and four part-time inspectors. On October 31, 1925, this force was reduced by the discontinuance of the services of one sanitary inspector furnishing his own auto transportation, and in May, 1926, a further reduction was made by the transfer to other service activities of one general inspector and one inspector furnishing his own auto transportation. The personnel remaining at the close of the fiscal year, consisting of two general inspectors, one inspector furnishing his own auto transportation, and four parttime inspectors, were separated from the service with the discontinuance of the work. 131 PUBLIC HEALTH SERVICE In the accompanying table the tabulated outline of the work for the year is shown: Yellow-fever prevention, Texas-Mexican border—Summary of work, fiscal year, 1926 Total area Border counties Nonborder counties Counties worked in Communities worked in Number inspection trips made Inspections of premises 9 23 394 817,190 5 18 379 795,931 4 5 15 21,259 Inspections of barrels Inspections of cisterns Inspections of other containers 67,223 39,464 1,910,241 63,091 36,144 1,874,874 4,132 3,320 35,367 2,016,928 I 1,974,109 42,819 1,925 491 ' 3,857 1,669 386 3,749 256 105 108 6,273 5,804 469 1,084 255 1,985 971 222 1,941 113 33 44 Total Barrels found breeding Cisterns found breeding Other containers found breeding Total Barrels found producing Cisterns found producing Other containers found producing Total Barrels protected Cisterns protected Other containers protected Total Percentage of containers found to each premise Percentage of containers breeding per premise, including culex Percentage of containers prolucing per premises, including culex Percentage of containers breeding per container, including culex 3,324 3,134 190 60,019 35,040 4,612 57,042 31,877 4,612 2,977 3,163 99,671 93,531 6,140 2. 46 .076 .0406 .031 ACTIVITIES RECOMMENDED BY THE ADVISORY COMMITTEE ON THE EDUCATION OF SANITARIANS AND THE FUTURE OF PUBLIC HEALTH IN THE UNITED STATES The following activities have been carried on in accordance with specific recommendations of the committee and with the committee's general policy: The recruiting of personnel.—For the purpose of arousing the interest of students in public-health work, 12 lectures were delivered by C.—E. A. Winslow and one by his assistant, Ira B. Hiscock. Three of these were given at high schools and secondary schools, one at a medical school, and the others at schools of arts and sciences. The training of sanitarians for the future.—An inquiry sent to State departments of health revealed that there had been employed by departments of health (mostly State departments) 77 medical school students during the summer of 1925 as a result of the promotion work of the International Health Board and the Public Health Service. An inquiry sent to 15 schools awarding graduate degrees in public health showed that, in 1925, there were awarded (not including the D.P.H. offered by New York University) 76 graduate degrees, while in 1924 only 62 such degrees had been granted. The training of sanitarians now employed.—The Public Health Service did not participate directly during the past year in encourag- 132 PUBLIC HEALTH SERVICE ing the attendance of health officers and other sanitarians at summer schools. There was a good enrollment in public-health courses at the 1926 summer schools, but a large proportion of the students were teachers. A questionnaire was distributed among 4,000 health officers and other sanitarians to ascertain more definitely the needs and desires of sanitarians in respect to supplementary academic instruction. There were received 274 replies showing a definite interest in the problem and indicating that a considerable number might enroll for summerschool instruction where suitable courses of two or three weeks' duration available at near-by universities or colleges. SUPERVISION OF INTERSTATE TRAVEL OF DISEASED PERSONS The supervision of the travel of diseased persons an common carriers in interstate traffic and the transportation of things from diseaseinfected localities, together with general sanitation conditions of the carriers, has been continued as provided for under the interstate quarantine regulations. CONFERENCE OF THE SURGEON GENERAL WITH STATE AND TERRITORIAL HEALTH OFFICERS In accordance with provisions in the act of July 1, 1902, the annual conference of the Public Health Service with State and Territorial health officers was held in Washington, D. C., on May 24 and 25, 1926. It was attended by delegates from 35 States, 1 Territory, and the District of Columbia. A two-day program was carried out in which the following subjects were discussed: 1. Further observations on the status of morbidity reports and the establishment of a morbidity registration area. 2. The sanitary control of shellfish. 3. A summary of the points brought out at the April, 1926, meeting of the Advisory Committee on the Education of Sanitarians held at the Bureau of the Public Health Service. 4. Plague—studies in transmission and geographical limitations of infectibility. 5. The present status of smallpox in the United States and measures being taken for its control. 6. Vaccination of dogs against rabies. 7. Present status of scarlet-fever biologic products. 8. Progress in the research work of the Public Health Service during the past year. 9. The sanitation of automobile garages and service and filling stations. Proposed regulation's for the manufacture and blending of tetrthyl lead. Distribution of ethyl gasoline. 10. The control of unsegregated lepers in the United States. 11. Some problems of county health work. DIVISION OF FOREIGN AND INSULAR QUARANTINE AND IMMIGRATION In Charge of Asst. Surg. Gen. S. B. GRUBBS QUARANTINE TRANSACTIONS During the fiscal year 1926 officers of the Public Health Service engaged in the administration of the United States quarantine laws inspected 17,056 vessels and 1,777,064 passengers and members of crews at the continental maritime stations. At insular stations 2,868 vessels and 378,414 passengers and members of crews were inspected. At foreign stations 6,774 vessels and 855,061 passengers and members of crews destined for ports of the United States were inspected. There were 5,019 vessels fumigated or disinfected at continental stations, 696 at insular stations, and 1,847 at foreign stations. At the border quarantine stations there were 67,209 travelers inspected, exclusive of the local interurban traffic. GENERAL PREVALENCE OF QUARANTINABLE DISEASES holera.—The reported incidence of cholera increased considerably over that of the previous year. This disease continued with but little abatement in the endemic centers in southern India. Marked exacerbations occurred in China, Siam, and the Philippine Islands. A sharp outbreak in Japan, probably due to importation from China, was quickly suppressed. The examination of potential carriers and the prohibition of the embarkation of those actually discovered at ports of embarkation in the Philippine Islands effectually prevented the introduction of this infection into the Hawaiian Islands and the United States. Plague.—The unusual prevalence of plague mentioned in my last report continued throughout the year. Although there were considerable fluctuations in the number of cases reported from specific localities, the general distribution of this disease is remarkably similar to that during the previous year, thus illustrating the difficulty of eradicating plague once it has become established. Smallpox.—This disease continued to occur throughout the world, including the -United States of America. Because of an epidemic in Florida a quarantine was imposed against that State by the quarantine board of the Bahama Islands and maintained for several weeks. The undue and prolonged incidence of smallpox in Los Angeles, Calif., aroused the apprehension of the sanitary authorities of the Territory of Hawaii so that it was deemed advisable to require per133 134 PUBLIC HEALTH SERVICE • sons embarking at ports on the Pacific coast of the United States to produce satisfactory evidence of immunity to smallpox before embarkation. This restriction was continued in effect from April 5, 1926, to June 17, 1926. Typhus fever.—There was very little change in the reported prevalence of typhus fever. Although this disease is widely distributed, it is not epidemic except in Soviet Russia. It is probable that the incidence in Russia is decreasing. Typhus reappeared in the Canary Islands, Italy, and Tripoli. It apparently increased in Czechoslovakia and Ireland and diminished in Lithuania and Poland. Yellow fever.—The number of cases of this disease reported was approximately the same as was reported during the previous year. However their distribution was more extensive since cases were from the Gold Coast, the Ivory Coast, Liberia, Nigeria and reported' Senegal (Africa), and Brazil, in South America. The sharp outbreak at Parahyba, Brazil, has caused some apprehension, but, due to the energy and promptness of the measures for its eradication, will probably soon be brought under control. CHANGES IN QUARANTINE PROCED LIRE One amendment to the quarantine regulations authorizing the Surgeon General to prescribe rules under which the six-month period between fumigations may be extended for, first, vessels plying regularly between ports not infected with plague; second, vessels whose construction does not favor the harborage of rats, was promulgated. In accordance with the terms of this amendment quarantine officers have been authorized to extend the period between fumigations for an additional six months in the case of certain classes of vessels if, upon careful inspection, no evidence of rat infestation or harborage is found. It is expected that this procedure will materially diminish the number of tankers fumigated. The official declaration that the cities of New Orleans, La., and Oakland, Calif., are free from plague, with consequent lifting of the special restrictions imposed during the last fiscal year, has materially lightened the work at the respective quarantine stations. The question of the disinfection of the rags imported into the United States for the manufacture of paper has for many years occupied the attention of this division. On December 3, 1925, the medical officers in charge of quarantine stations were advised that consular certificates of disinfection or origin will no longer be required as a prerequisite to admission of shipments of rags into the United States, its possessions or dependencies, and that when rags are obviously filthy or infected their admission into the United States should be refused. NEW QUARANTINE STATION AT MOBILE, ALA. In accordance with the terms of an act of Congress approved February 15, 1925 (Public, No. 425, 68th Cong.), authorizing the i r PUBLIC HEALTH SERVICE 135 Secretary of the Treasury to remove the quarantine station situated at Fort Morgan, Ala., to Mobile at a cost not to exceed $300,000, the Governor of Alabama on May 14, 1925, executed a deed transferring approximately 80 acres of Sand Island, located in Mobile Harbor, to the United States as a site for the new quarantine station. By the second deficiency act approved March 4, 1925 (Public, No. 631, 68th Cong.), $200,000 was made available for beginning the construction. The $100,000 necessary for the completion of the work was appropriated by the next Congress (Public, No. 35, 69th Cong.) and approved by the President March 2, 1926. Construction of the new station was commenced in the spring of 1926 and, if the contracts are fulfilled, it will be completed February 24, 1927. The plans for the station, as approved, provide for the following: A dredged basin—a widening of the main ship channel—to serve as an anchorage and mooring place for vessels and to be provided with five clusters of mooring dolphins; a wharf of timber construction; buildings designated and described as follows: No. 1. Office, storehouse, and carpenter shop; one story, hollow-tile construction. No. 2. Disinfecting plant, laundry, and machine shop; one story, hollow-tile construction. No. 3. Detention barracks, attendants' quarters, kitchen, and mess; two stories, hollow-tile construction, accommodating 120 steerage passengers, on double-tier bunks, and 32 cabin passengers in 16 rooms. No. 4. Detention hospital and nurses' quarters; two stories, hollowtile construction, with accommodations for 24 patients (in 5 wards with 4 beds each and 2 rooms with 2 beds). No. 5. Double set of attendants' quarters; two stories, brick construction. No. 6. Quarters for medical officer; two stories, brick construction. No. 7. Quarters for medical officer; two stories, brick construction. No. 8. Garage and quarters for attendants; two stories, hollow-tile construction. No. 9. Fumigating building; one story, concrete construction. Those of the buildings requiring heating will be equipped with individual heating plants. Water for domestic uses and fire protection, electric current, and telephone service is provided by extension from the city of Mobile, across Choctaw Channel. ACQUISITION OF THE TEXAS QUARANTINE SYSTEM By an act of Congress approved June 5, 1920 (41 Stat. 875), $90,071 was appropriated for the transfer and purchase of the Texas quarantine stations. Considerable difficulty has been experienced in consummating the purchase of these stations because of the inability of the State of Texas to prove title to all of the properties. The State authorities were able to furnish title for the stations at Sabine and Aransas, but not for those at Point Isabel and Laredo. The site of the station at Galveston had been patented to the Government of the United States on June 28, 1912. 136 PUBLIC HEALTH SERVICE On August 14, 1924, the Comptroller General of the United States decided that the appropriation act of June 5, 1920, did not permit the purchase of individual stations of the quarantine system but only of the system as a whole, so that it was necessary for the Congress to pass a new act (approved April 26, 1926) authorizing the purchase of those stations to which the State of Texas can give satisfactory title. Investigation of the titles to those stati9ns with a view to the completion of the transfer is now in progress. INTERNATIONAL RELATIONS Two meetings of the Permanent Committee of the International Office of Public Hygiene were held during the year—one in October and one in May. The United States was represented by Surg. W. W. King. Subjects covering a considerable portion of the field of public health were discussed. An international conference called by the French Government to consider a revision of the sanitary convention at Paris in 1912, was held in Paris from May 10 to June 21, 1926, and was attended by delegates from 67 countries and dominions. The United States was represented by Surg. Gen. H. S. Cumming, Senior Surg. Taliaferra Clark, and Surg. W. W. King. Since the changes in the treaty were, on the whole, satisfactory, the American delegates signed, but with the following reservations: The plenipotentiaries of the United States of America declare formally that the signature by them of the international sanitary convention of this date should not be interpreted in the sense that the United States admits that the signatures of the representatives of a Government which they have not recognized or an adhesion of such a Government is equivalent to the signature or to the regular'adhesion of the power in the name of which the Government signs or adheres. They declare in addition that the participation of the United States of America in the international sanitary convention of this date carries no contractual obligation of the United States toward a signatory or adhering power represented by a Government or body which the United States does not recognize as corresponding to the Government of that power. The plenipotentiaries of the United States of America declare also that their Government reserves the right to decide if, from the point of view of the measure to be applied, a foreign area should be considered infected and to determine the measures which should be applied under special circumstances to arrivals in its own ports. VIOLATION OF QUARANTINE LAWS During the fiscal year the department assessed fines aggregating 441,395 for violations of the act of February 15, 1893, because of the failure of masters of vessels to present American consular bills of health. 137 PUBLIC HEALTH SERVICE TRANSACTIONS AT CONTINENTAL QUARANTINE STATIONS Transactions at continental quarantine stations for the ascal year ended June 30, 1926 Stations Aberdeen, Wash.! Atchafalaya (Morgan City), La Baltimore, Md Beaufort, S. C Boca Grande, Fla Boston, Mass Brownsville, Tex.2 Brunswick, Ga Cape Fear (Southport), N. C Cedar Keys, Fla Charleston, S. C' Columbia River (Astoria), Oreg Coos Bay, Oreg Cumberland Sound (Fernandina), Fla Delaware Breakwater, Del Del Rio, Two Eagle Pass, Tex.2 Eastport, Me El Paso, Tex.2 Eureka, Calif Fall River, Mass Fort Bragg, Calif Fort Monroe, Va Freeport, Tex Galveston, Tex Georgetown, S. C Gloucester, Mass Gulfport, Miss Hidalgo, Tex.2 Jacksonville, Fla., Ketchikan, Alaska Key West, Fla Laredo, Tex.2 Marcus Hook (Philadelphia), Pa PassenVessels Vessels gers and infumi- crews inspected gated spected 75 72 0 702 0 29 968 0 21 0 332 0 7 212 0 4 64 0 164 22 0 31 147 18 124 17 8 2 6 0 0 0 0 7 41 0 731 106 593 2 0 58 0 163 12 275 0 0 0 0 0 0 2 0 0 272 0 148 0 0 31 0 27 0 20 0 1,056 470 Stations Vessels 'Vessels Passeninfumi- gers and spected gated crews inspected , ' Miami, Fla. 547 Mobile, Ala 355 0 0 Monterey, Calif 17 24,241 New Bedford, Mass 2, 102 0 New Orleans, La 0 590 Newport, Oreg 1 100,638 Newport, R 1 4,470 1,371 New York, N. Y Y N. Ogdensburg, 9 592 20 Pascagoula, Miss 117 2,045 Pensacola, Fla 37 0 Perth Amboy, N. J 5, 197 Port Ageles, Wash 8 Port San Luis, Calif 9 156 5,081 Portland, Me 377 645 Port Townsend, Wash__ Presidio, Tex., 0 100 278 Providence, R. I Roma, and Grande I Rio 0 114 Tex., 410 2,270 Sabine, Tex 18 3,076 St. Andrews, Fla 0 0 St. George Sound, Fla_ _ 3 27,318 St. Joseph, Fla 298 San Diego (Point 783 Loma), Calif 697 510 0 San Francisco, Calif 1, 250 28,105 San Pedro, Calif 0 1,567 Santa Barbara, Calif____ 163 22,417 Savannah, Ga 0 17 Seattle, Wash 9 0 South Bend, Wash 336 1,534 Tampa Bay, Fla 3 2,023 Vineyard Haven, Mass_ 0 4,478 Washington, N. C 0 246 West Palm Beach, Fla.5_ 40,983 17,056 Total 28,189 3,161 0 18,425 111 10,880 0 0 0 536 529 95,695 0 0 0 38 1, 179 1,072,903 73 0 6 115 67 3,845 21 1,035 205 0 0 353 45 6, 111 49 33,010 0 75 2 10,088 0 161 12 0 0 2,887 13,938 317 0 0 14 514 240 0 26 171 9 70 0 0 0 17,175 79,276 52,518 0 4,958 0 378 8,724 23 0 0 5,019 1, 777,064 36,312 1 Formerly Hoquiam, Wash. 2 Border stations. Figures do not include local travelers who, however, were subjected to cursory inspection. Through travelers were given close examination. 3 Formerly St. Johns River. Formerly Biscayne Bay. Opened Apr. 1, 1926. SUMMARY OF TRANSACTIONS AT NATIONAL (CONTINENTAL AND INSU- I AR) QUARANTINE STATIONS FOR THE FISCAL YEAR ENDED JUNE 30, 1926 Total inspection:1 Vessels, 19,924; crew, 1,221,077; passengers, 934,401. Total persons inspected, 2,155,478. Vessels passed on certificate of ship's medical officer, 343. An inclusive figure, regardless of treatment or report elsewhere. PUBLIC HEALTH SERVICE 138 Persons and vessels detained or treated—those inspected only not included Nature of infection Yellow Rodent Human SmallTyphus Cholera Leprosy Total fever plague plague pox Infected vessels 1 Number of cases 3 Number of crew detained Number of passengers detained Persons bathed and disinfected Persons vaccinated Laboratory examinations (persons) 7.. Vessels fumigated: 8 HCN SO2 CNC 1 HCN and SO2 HCN and CNC1 CNCI and SO2. Zyklon "B" CH OH CHOFI and KMn04 24 30 206 595 6 1,014 178 299 15,244 2 4 104 14 157 2 1,000 1,967 1,486 11 1, 181 27 22 3 23 13 230 128 238 1,024 9, 779 4 4 86 44 4 3 4 Total vessels fumigated 6 7 4 3 2 10 3 33 50 1,139 1,341 625 16,268 9,996 1,000 1,974 1,491 11 1, 183 27 22 3 4 5, 715 1 Vessels with cases on board on arrival or reported en route. 2 Two cholera-infected vessels were remanded to Cebu for treatment after removal of the sick. 3 Includes carriers. Twelve cholera carriers were discovered on vessels arriving at Manila. 5, 6 Two hundred and four seamen and 1,014 passengers from Amoy were detained at Manila because of an epidemic of human plague at Amoy. 7 Includes microscopical examinations of blood, excreta, tissue, etc. Includes vessels fumigated after passing quarantine in accordance with provisional pratique. Periodic fumigations for destruction of rodents are listed in the "Rodent plague" column. Vessels fumigated are entered in the columns indicating the disease for which fumigated, as well as opposite the fumigating agent used. Number of rats destroyed on ships, 30,979; rats examined, 21,731. REPORTS FROM CONTINENTAL QUARANTINE STATIONS Boca Grande, Fla.—Acting Asst. Surg. H. P. Bevis in charge. Post office and telegraphic address Boca Grande, Fla. On June 30, 1926, the buildings on La Costa Island, which had been occupied under authority of a revocable license from the War Department dated January 25, 1905, were abandoned. The Government property was transferred to Boca Grande and to Mullet Key. The new headquarters for the station is at Boca Grande, Fla. The condition of this station, due to deterioration, was subh that further exposure to the severe storms normally encountered in this vicinity would endanger the lives of the attendants and the property of the Government. It would have cost a minimum of S16,000 to put the buildings in repair. Boston, Mass.—Surg. Friench Simpson in charge. Post office and telegraphic address Gallops Island, Boston, Mass. In 148 (or approximately 70 per cent) of the 212 vessels fumigated no rats were found upon search following fumigation. The remaining 64 vessels (approximately 30 per cent) yielded 642 rats, of which 362 were identified as Rattus aleveandrinus, 262 Rattus rattus, and 4 Rattus norvegicus. Three hundred and fifty rats were found in the holds, and 292, or 45 per cent, were found in the superstructures, repeating previous experience that a considerable proportion of a ship's rats are found outside of the holds. 139 PUBLIC HEALTH SERVICE No vessel arrived with suspected quarantinable disease aboard. Pending confirmation of the diagnosis of a case suspected to be chicken pox,the crew of one vessel, numbering 24 persons, were vaccinated against smallpox. Twenty of those vaccinated showed an acceptable immunity reaction within 36 hours. The inspection of third-class passengers for vermin was continued. Three thousand one hundred and sixty-five persons, approximately 25 per cent, of arriving alien passengers were examined intensively for vermin. Only 15 individuals, all female, were found to be vermin infested. The low rate of infestation found on arrival, as compared with former years, attests the thoroughness of the preliminary inspection conducted by medical officers of the Public Health Service abroad and the cooperation of ships' officers in disinfesting passengers en route. The inoculation of guinea pigs with an emulsion of pooled splenic tissue of rats recovered from fumigated vessels was continued. No plague infection was found. The rats were classified as follows: Species R. norvegicus R. alexandrinus R. rattus Total Male Female Total ex- Noted amined pregnant Foeti noted 15 107 193 15 128 166 30 235 359 1 29 35 9 176 228 315 309 624 64 413 Of the 968 vessels inspected 325 had called at ports considered to be infected with one or more of the quarantinable diseases. It appears, therefore, that approximately one vessel out of three visited ports infected with quarantinable disease, the possible exposure to these diseases being most common in the cases of plague and smallpox, frequent in typhus and cholera, occasional in yellow fever, and rare in leprosy and anthrax. Cumberland Sound, Fla.—Acting Asst. Surg. D. G. Humphreys in charge. Post-office and telegraphic address, Fernandina, Fla. Arrangements have been completed for the return to the War Department of the reservation on Amelia Island, which has been used as a quarantine station under authority of a revocable license dated January 27, 1905. Key West, Fla.—Acting Asst. Surg. J. Y. Porter, jr., in charge. When the American steamship Benjamin Brewster arrived from Rotterdam, Holland, one seaman was found to be convalescing from smallpox. The sick man was removed to Marine Hospital No. 10. The other members of the crew were vaccinated and the vessel remanded to Galveston, the port of destination. Because of the dilapidated condition of the hulk Wisteria, formerly used for the housing of detained passengers, it was abandoned late in April and sold after the serviceable property on board had be been transferred to Marine Hospital No. 10. The persons to the board on kept be will t treatmen or on observati detained for vessel on which they arrive or at Marine Hospital No. 10. Marcus Hook, Pa.—Surg. F. A. Carmelia in charge. sugar, The principal cargoes entering this port direct are fruit, mmbulk ports; Gulf and n Carribea from oil logwood, and crude 140 PUBLIC HEALTH SERVICE eral oil from western South American, northern African, Spanish, and Norwegian ports; china clay and general cargoes from North Atlantic, European, and southeastern African ports (chiefly British and Spanish), with a few "round-the-world" transits; cork from Spanish Mediterranean ports; and wood pulp and lumber from Canadian ports. The passenger traffic is largely incidental to cargo vessels having limited passenger accommodations and carrying up to 25 passengers. Only one large, strictly passenger liner entered the port during the year, the German steamship Derflinger from Bremerhaven. The practice of combining the quarantine inspection and the medical inspection of aliens was continued, conserving both the time of the vessel and official effort. It was not found necessary to detain anyone for quarantinable disease during the year. The sanitary status of both vessels and personnel continues to improve from year to year. Since relatively few regular line vessels call direct at this port, the percentage requiring fumigation continues relatively. high. Of 1,056 vessels inspected, 313 (29 per cent) were granted provisional pratique and fumigation ordered following discharge of cargo. Sixty-two per cent of these vessels were from ports considered to be plague infected; 36 per cent were ordered to be fumigated because of the expiration of the six months' period between fumigations; and 2 per cent were ordered to be fumigated because of the expiration of the three months' period between fumigations. Seventy-two per cent of the vessels entering under provisional pratique and requiring fumigation completely discharged their cargo and were fumigated, while 28 per cent were remanded to some other port for fumigation. This represents an increase of 12 per cent in the number of vessels remanded to other ports over the number remanded during the last fiscal year. The growing tendency of vessels from foreign ports to call at several ports in the United States complicates the enforcement of provisional pratique and necessitates remanding to one, two, or even three other ports before fumigation after discharge of cargo is possible. This situation is of particular significance if fumigation is mandatory. The increased number of vessels which load and discharge cargo simultaneously at several of the United States ports of call complicates the enforcement of provisional pratique and the exercise of remanding. The number of vessels remanded to Philadelphia from other ports for fumigation is increasing each year, because this port is the final port of call for several lines running around the world and from the Far East. Forty-seven per cent of the total number of fumigations were done on vessels in these trades. Two hundred and twentytwo of the vessels fumigated had previously entered some other United States port and were remanded to Philadelphia for fumigation. In addition, 54 vessels were remanded from United States ports via Philadelphia to other United States ports. New Orleans, La.—Surg. D. C. Turnipseed in charge. On November 14, 1925, the headquarters of the station was removed from quarantine, Louisiana, to the city of New Orleans. Coincident with this transfer the activities of the city station were considerably increased at the expense of the station at quarantine, PUBLIC HEALTH SERVICE 141 Louisiana, so that at present most of the vessels from foreign ports are boarded and inspected at the Flood Street station in the city of New Orleans. During the close quarantine season (April 1 to November 1) the temperature of all persons arriving from ports in the zone where yellow fever may be present is taken, and all persons with fever which can not be otherwise explained are removed to Marine Hospital No. 14 for observation and diagnosis. All vessels with sickness on board are required to stop for quarantine inspection at the lower station, 90 miles down the river. Certain vessels carrying perishable cargo which would ordinarily arrive at New Orleans after sundown are, upon request, inspected at the lower station between the hours of 7 a. m. and 3 p. m. This latter procedure affords the fruit-shipping interests a 24-hour boarding schedule and eliminates the necessity for night inspection during the close quarantine season. When New Orleans was declared free from plague infection on October 1, 1925, the supervision of the fumigation of vessels, which had been administered as a part of outgoing quarantine measures, was returned to the medical officer in charge of the quarantine station. Two vessels arrived with smallpox on board. In both instances the patients were removed and isolated until recovered. All members of the crew not showing evidence of recent successful vaccination were vaccinated and detained until immune reactions or evidence of successful vaccination appeared. The quarters occupied by the patients on board the vessels were fumigated. Three lepers who had absconded from Carville, La., were detained at quarantine, Louisiana, from July 1 to November 1, 1925. New York, N. Y.—Surg. Carroll Fox in charge. Post-office and telegraphic address, Rosebank, Staten Island, N. Y. Scientific studies inaugurated in previous years have been continued and additional research undertaken with the aim of improving quarantine procedure and technique. Hoffman Island, situated in the lower bay 3 miles below quarantine headquarters, has been maintained for the purpose of hospitalization, delousing, and detention. Swinburne Island has remained inactive for two years, and should it be required for detention and isolation much time and money would be consumed in getting it ready. Additional personnel would also be required to operate it. Port stanitary statements are issued from the station office at the customhouse, New York City, N. Y. ADMINISTRATION The major activities of the station are effected through three divisions—boarding, fumigation, and'laboratory. 142 PUBLIC HEALTH SERVICE Station personnel Classification Commissioned officers Acting assistant surgeons Pharmacists Consulting bacteriologist Nurses Clerks Pilots Marine engineers Other employees Total On duty On duty June 30, June 30, 1925 1926 3 11 2 1 2 9 3 4 132 10 2 1 2 9 3 4 111 167 145 It will be seen that there has been a reduction of 22 in the number of employees during the year. After 33 years and 4 months' service at the New York Quarantine Station, Senior Pilot James J. Dillon died on May 17, 1926. Captain Dillon was employed by the State of New York from September 1, 1892, until the quarantine station was transferred to the Public Health Service on March 1, 1921. From that date until his death he was employed continuously by the service. The old wharf on the north side of the reservation was replaced by a new L-shaped pier and the basin was dredged to a depth of 12 feet at mean low tide. The old frame and galvanized sheet iron sheds on the south side of the Rosebank Reservation have been replaced by new concrete onestory warehouses, constructed by station labor from material purchased for this purpose. These buildings are a valuable addition to the station equipment, affording better protection and greater security to the property stored therein, as well as greatly improving the appearance of that section of the reservation. A new fire-resisting roof was installed on building No. 1, Rosebank. Rooms in building N.7, Rosebank, were papered or painted, as were a number of rooms in building No. 2, Rosebank, quarters Nos. 2 and 3. The tug Pyxie was rechristened Henry R. Carter by bureau order. The tug Beetle was transferred from the Shipping Board and arrived at the station on June 3, 1926. The coal dock at Hoffman Island was repaired and is now in good condition for storage of coal. A new flagpole was erected ,at Hoffman Island. Minor repairs were made to the walls and chimneys of brick buildings, and the frame isolation hospital building at the island was painted both inside and out by the station force during the past winter and spring. BOARDING DIVISION The personnel regularly assigned to the boarding division consists of five medical officers, two of whom are detailed from Ellis Island for the medical inspection of aliens, two male and two female inspectors. From time to time during the year medical officers temporarily assigned to the station have been detailed to the boarding division for instruction and training. 143 PUBLIC HEALTH SERVICE Although 1,348 vessels arrived from ports in which quarantinable diseases were known to exist, no case of quarantinable disease was detected, nor were any vessels detained. A total of 16 persons-11 seamen and 5 passengers—was removed from vessels because of suspected quarantinable disease-5 for smallpox, 2 for plague, for leprosy, 1 for yellow fever, and 4 for typhus. These, however, after further study and observation, were released as negatives. Eighty-six persons showing evidence of body-lice infestation were bathed and disinfected on board vessels. FUMIGATION DIVISION The personnel of the fumigation division consists of a medical officer in charge of the division, 3 medical officers in charge of fumigatincr crews, 1 assistant sanitary inspector in charge of a crew, 1 clerk, 1b messenger, 4 fumigating crews comprising 4 assistant foremen and 19 fumigators, and a trapping crew of 1 foreman and 3 men. Fumigation.—Vessels aggregating approximately 4,148,760 net tons were fumigated. Hydrocyanic acid gas was used exclusively, the following methods being used: Barrel generation method: Hydrocyanic acid gas, straight Hydrocyanic acid-cyanogen chloride mixture Liquid hydrocyanic acid-cyanogen chloride mixture Zyklon-B (hydrocyanic acid plus tear gas) 2 60 789 308 22 vessels. vessels. vessels. vessels. The 10,144 rats found after fumigation were distributed as follows: Mess and ship's stores Holds and all cargo spaces Crew's quarters and staterooms Other superstructures 1,081, or 10.65 per cent. 7,231, or 71.29 per cent. 230, or 2.27 per cent. 1,602, or 15.79 per cent. If the term "superstructure" be taken to mean quarters, staterooms, chart rooms, and such compartments as are actually on or above the main deck, it will be seen that 1,832 rats, or 18.06 per cent, were recovered from the superstructures, and 8,312, or 81.94 per cent, were recovered from the holds, cargo spaces, and ship's storerooms. Experience gained in routine fumigation by experimental work with cyanogen products indicates that the barrel generation" method of hydrocyanic acid gas fumigation is less efficient than the liquid hydrocyanic acid gas mixture or Zyklon—B. The amount of hydrocyanic acid gas evolved when sodium cyanide and sodium chlorate are added to a mixture of hydrochloric acid and water varies considerably. Further important considerations are the difficulty of handling and transporting the equipment required for the generation of gas and the greater number of persons required for conducting the fumigation. With the improvement in the mechanical equipment used for fumigating with liquid cyanide mixtures and with larger amounts of this material available, the number of vessels fumigated by this method increased steadily throughout the year. Considered solely as a lethal agent, liquid hydrocyanic acid gas introduced into vessels by means 2 Fifty-nine supervised and one fumigated by station. 144 PUBLIC HEALTH SERVICE of a well-designed spray apparatus is the agent of choice. With the mechanical equipment now used it is impossible to regulate the doses for small compartments accurately, so that its use in sleeping quarters and staterooms is hazardous because of liability of overdosing. There is probably a certain element of danger of spontaneous decomposition due to exothermic polymerization in handling liquid cyanide. Certain of the liquid cyanide manufacturers have discontinued the practice of shipping this material by common carrier. At this station the liquid gas is transported to the vessel to be fumigated by boat. Zyklon—B, a product of German manufacture, consisting of liquid hydrocyanic acid incorporated in a calcined and granulated silicious earth, has been studied intensively. From the standpoints of convenience, ease of handling, and safety to the public and fumigators Zyklon—B represents a distinct advance in cyanide fumigation. Small compartments can be dosed with accuracy. Trapping.—Trapping was carried on by one crew consisting of a foreman and three men. Vessels subject to rat-proofing surveys were trapped for the purpose of controlling the work in progress. Other vessels, whose • records showed a high rat infestation, were trapped both before and after fumigation. Double-action snap traps were used in the proportion of 60 traps per 1,000 net tons. A large number of cage traps were used on the piers in order to secure live rats for the flea survey conducted by the laboratory division. The results of pier trapping have been discouraging. The only two vessels trapped before fumigating yielded 25 rats. Subsequent fumigation of these vessels yielded 67 rats; 2,332 rats were recovered by trapping 769 ships which were not treated by fumigation; 179 vessels were trapped immediately after being fumigated; 2,325 rats were recovered by fumigation, and subsequent trapping yielded 531 rats; that is, 2,888 rats were trapped on 950 vessels, distributed as follows: Mess and ship's stores Holds and all cargo spaces Crews' quarters and staterooms Superstructures 248, or 8.59 per cent. 2,159, or 74.76 per cent. 94, or 3.23 per cent. 387, or 13.43 per cent. If the term "superstructure" be taken to mean quarters, staterooms, chart rooms, and other compartments on or above the main deck, it will be seen that 481 rats, or 16.66 per cent, were recovered from the superstructure and 2,407, or 83.34 per cent, from the holds and cargo spaces and ship's storerooms. It is believed that careful trapping of vessels will serve as an index of rat infestation. Rat-infested vessels which for any reason can not be fumigated should be thoroughly and completely trapped while in port. RAT-PROOFING OF VESSELS The rat-proofing of vessels, inaugurated at this station about 18 months ago, has progressed steadily and satisfactorily. Seventyfour vessels, representing some of the most important steamship lines entering the port, have been surveyed and work is in progress on 26 of this number. All of these are large passenger vessels and among the list are six of the largest and finest vessels in the world. In addition to the United States lines, the most important English, Norwegian, Svyedish, Danish, German, Italian, and Dutch companies PUBLIC HEALTH SERVICE ' 145 are cooperating. Rat-proofing is carried on not only in New York but in Southampton, Bremen, Dantzig, Buenos Aires, Gothenburg, and Bergen. Realizing that more efficient and economical work is done by trained workmen, several of the companies maintain regular crews of mechanics and carpenters who work on the different ships while in port, rat-proofing under the direct supervision of service inspectors. Follow-up inspections are carefully and thoroughly made on each return to New York, so that satisfactory progress is insured and important data are collected and recorded with reference to variations in rat infestation and activity on board during each trip. The ships' officers maintain a special log of rats trapped or killed and those seen or heard by members of the crew, and this information, together with that obtained at previous surveys, is used by the inspector in checking the results of the rat-proofing. The results of rat-proofing are illustrated in the case of a 50,000ton passenger vessel plying regularly between New York and England. On this vessel, which is now approximately 55 per cent rat proof, rat trapping was practiced for about one year before ratproofing was inaugurated. The average yield was 50 rats per round trip voyage. During the period of more than one year since ratproofing was begun, the rat catch on this vessel has progressively decreased and for several voyages has averaged less than six rats without fumigation or other rat eradicative measures. Numerous inspections of rat-proofed sections of vessels indicate that if rat-proofing has been done exactly in accordance with specifications, rats have been eliminated from the treated sections and they do not reappear even though they are definitely known to flourish in other parts of the same vessel. The provision storeroom, cold-storage plant, and baggage room, all of which communicated with one of the after holds of a certain 11,000-ton passenger vessel, were rat infested. In spite of periodic fumigation the ship's crew trapped an average of 20 rats per trip. A careful survey of this vessel showed much evidence of rat harboring and nesting in the after section and 80 rats were uncovered and killed during the process of rat-proofing. Intensive rat-proofing measures, embracing the elimination of rat-harboring places, were carried out and after seven months the most rigid inspections each time the vessel comes to New York fail to disclose evidence of rat reinfestation. Even if rats should enter the vessel, harboring and breeding would be discouraged, as conditions favorable to rat life have been eliminated. Similar satisfactory results have been reported from many other vessels. A large-scale cross-section model of a ship, showing on one side typical .conditions favoring rat life, harborage, and activity and on the other corrections of such conditions, was prepared at this station and is now being exhibited at the Sesquicentennial Exposition at Philadelphia, Pa. LABORATORY DIVISION On July 27, 1925, Surg. C. L. Williams was placed in charge of the laboratory. As station work would permit other officers were assigned to the laboratory as assistants and for special duty. A survey of the fleas obtained from rats trapped along the water front is being made. This survey has already demonstrated that 146 PUBLIC HEALTH SERVICE rats are relatively few in number on the docks, less than one rat being captured per 100 traps set. All fleas examined were Ceratophyllus fasciatus. A survey of the fleas obtained from rats fumigated or trapped on ships has been inaugurated. A record is keptof the ship, the ports visited, the cargo carried, the number and species of rats, and the number and species of fleas. Although there are a number of causes of error inherent in this method, the principal one being due to fleas leaving the rats during the process of fumigation, it yet furnishes certain data of considerable value. It has been noted that the rats on ships running between New York and north European ports (north of Spain) are infested almost exclusively with C. fasciatus, while on all other ships X. cheopis predominates. Tile survey has shown that fleas are much more numerous on ship rats in warm weather than in cold. This applies to ships coming from tropical ports as well as to those from cold climates. Eight species of fleas have been taken from ship rats with X. cheopis markedly predominating, C. fasciatus next, and all others in neglible numbers. The fact that ship rat fleas are almost exclusively X. cheopis and C. fasciatus is strong evidence of their superior adaptability with consequent wide distribution as compared with other species. It appears that, as far as plague in rats is concerned, we may confine our flea investigations to these two species. The records show that both fleas and rats are affected by the ports visited and the cargoes. Vessels from the Orient, those continuously traveling around the world, those in the trade with the east coast of South America, and those running to tropical ports in general have more rats and fleas than ships on other routes. Fruit ships have the most rats and fleas and tankers (all cargoes) the least. Sugar ships while infested with about the average number of rats, carry very' few fleas. Surg. C. V. Akin and Acting Asst. Surg. G. C. Sherrard were engaged in a special investigation of the relative merits of the several cyanogen products used an the methods followed in ship fumigation from the standpoints of (1) killing efficiency; (2) safety to the public and fumigators; and (3) cost. If lethal efficiency .only be considered, the cyanogen products tested stand in the following order: (1) Liquid hydrocyanic acid (96-98 per cent) straight. (2) Liquid hydrocyanic acid (96-98 per cent) to which is added 20 pm cent of liquid cyanogen chloride for "tear effect." (3) Zyklon-B, a product of German manufacture, consisting of a measured amount of liquid hydrocyanic acid plus varying percentages of "tear gas" incorporated in a granulated, calcined, silicious earth "diatomite." (4) Hydrocyanic acid gas generated by mixing sodium cyanide with sulphuric acid and water. (5) Hydrocyanic acid-cyanogen chloride mixture generated by mixing sodium cyanide and sodium chlorate with hydrocyanic acid and water. (6) "Calcium cyanide," a product of American manufacture, one-half of which, by weight, is hydrocyanic acid, liberating gaseous hydrocyanic acid when acted on by atmospheric moisture. NOTE.—Numbers 1, 2, and 3 are approximately equal as killing agents, variations noted being due in all probability to the amounts of hydrocyanic acid gas actually introduced. PUBLIC HEALTH SERVICE 147 If accuracy of dosage and safety of handling are considered, Zyklon-B is superior to all other cyanogen products tested and used on this station. The initial cost of liquid hydrocyanic acid-cyanogen chlorate mixture and Zyklon-B is practically the same. Theoretically the "barrel generation" method, using sodium cyanide and sodium chlorate with a mixture of hydrochloric acid and water, is cheapest, but when the expenses for extra labor, equipment, transportation, and loss of ship time are considered no saving can be demonstrated. Of even greater importance is the fact that the "barrel generation" method produces an extremely variable amount of hydrocyanic acid gas with a relative efficiency of approximately one-fourth that of liquid hydrocyanic acid or Zyklon-B. The use of Zyklon-.-B for superstructure compartments and liquid hydrocyanic acid for holds is ideal for large stations with trained personnel. Zyklon-B has many advantages and is recommended for smaller stations because it is safer than the "barrel generation method. Laboratory division transactions Total rats examined Total fleas examined Guinea-pig inoculations Rats found plague infected Weil-Felix reactions performed (positive) Weil-Felix reactions performed (negative) Smallpox vaccinations performed Smallpox vaccinations inspected and cards issued Blood counts made Blood smears examined Buboes punctured, suspected plague (negative) Tissue smears examined for leprosy (negative) Specimens of urine examined for clinical diagnosis Tests for Widal reaction Cultures examined for diptheria Sputum examined for tuberculosis Triple typhoid vaccination administered Vessels boarded by laboratory officers Consultations in cases outside of service work Dipththeria culture tested for virulence Cultures examined for meningitis 12,987 3,268 1,203 0 3 32 173 137 24 26 2 8 55 11 7 6 1 69 8 1 . 88 HOSPITAL, DETENTION AND DELOUSING The personnel attached to Hoffman Island was reduced from 63 to 32. Nineteen seamen, 16 with measles and 3 with chicken pox, were transferred from Marine Hospital No. 21 at Stapleton, Staten Island, N.Y. 3 Classification of fleas: Fleas from rats fumigated and trapped on vessels— Xenopsylla cheopis Xenopsylla astia Xenopsylla brasiliensis Ceratophyllus fasciatus Ceratophyllus sp Leptopsylla musculi Ctenocephalus canis Pulex irritans Fleas from rats trapped on plers—Ceratophyllus fasciatus Total fleas 2,623 27 4 546 4 17 7 1 3, 229 39 3, 268 148 PUBLIC HEALTH SERVICE Hoffman Island transactions Passengers detained (including 4 for delousing) Seamen detained Total days detained Seamen in hospital Total bpspital days Pieces of baggage fumigated 5 20 19 211 13 GENERAL A number of officers have been assigned to the station temporarily for training in quarantine procedure before being detailed to duty at foreign ports. All of the medical officers regularly assigned to the. station have been given opportunities to familiarize themselves with the major activities of the station. Pensacola, Fla.—Acting Asst. Surg. C. W. D'Alemberte in charge. On June 30, 1926, the American barge George T. Locke arrived at Pensacola Quarantine Station three and one-half days from Fron.tera, Mexico, with a cargo of bananas. One member of the crew was found to have a temperature of 38.6° C. and gave a history of having had a chill on the night of June 28. The crew of the barge was removed to the Pensacola Quarantine Station, and the barge was fumigated for the destruction of mosquitoes and released. Routine laboratory examinations of the patient were negative, and on the 2d day of July the men were released from quarantine, as the temperatures of all were normal, and a diagnosis of influenza was•made in the caseof the member of the crew who showed a rise of temperature upon arrival in port. Perth Amboy, N. J.--Acting Asst. Surg. Charles W. Naulty, jr., in charge. On June 29, 1926, a conference to discuss the matter of the quarantine anchorage was held in the office of the district Army Engineer. It is expected that a new channel, 400 feet wide and 30 feet deep,. will be dredged in the harbor to be completed in about two years, and that a channel, 200 feet wide and 30 feet deep, will be ready for use soon. The channel will be marked by gas buoys and permanent bewons, so that it may be used at night. Port Townsend, Wash.—Surg. W. A. Korn in charge. The S. S. Wheatland Montana arrived at Port Townsend January 15, 1926, from Shanghai, China. En route, one member of the crew died and was buried at sea. From the history obtained from the master of the vessel the disease evidently was smallpox. The vessel was remanded to Diamond Point Quarantine Station, where appropriate measures were taken, and the entire crew of 37 vaccinated. The vessel later was released, but eight of the crew were detained for observation. Two days later, one of those detained, an oiler, who had never been vaccinated, developed hemorrhagic smallpox, ending in death. No further cases occurred. Providence, R.1.—Senior Surg. H. S. Mathewson in charge. Postoffice and telegraphic address, 403 Federal Building. In August, 1914, the former cruiser Newark was brought to Providence and arranged for the housing of persons detained in quarantine. The Newark remained in Providence Harbor until May, 1918, when it was returned to the Navy for use as a hospital ship during PUBLIC HEALTH SERVICE 149 the war. The vessel was returned to Providence for the use of the Quarantine Service in June, 1919. Late in 1925 it was recommended that the Newark be returned to the Navy Department and that vessels whose personnel had to be detained be remanded to the quarantine station at Boston or New York. In February, 1926, a naval board inspected the Newark and made recommendations for its disposition. A board of medical officers of the Public Health Service was convened at Providence on May 4, 1926, to dispose of the property of that service still on board the Newark. This property having been disposed of June 28, 1926, by transfer to other stations of the service, the hulk was turned over to the Navy Department on July 2, 1926, and was towed to the naval training station, Newport, R. I. The remaining floating property of the station, consisting of the launch Hugh Wrd and the small unnamed launch, was removed to the New York Quarantine Station by the service tug Henry R. Carter. Sabine, Tex.—Surg. A. R. Sweeney in charge. Post-office and telegraphic address, Port Arthur, Tex. The Lake Sabine district comprises the ports of Beaumont, Port Arthur, Orange, Port Neches, Sabine, Sabine Pass, and other small ports situated on the Sabine River, Sabine Lake, and the Neches River. Recently Lake Charles, La., has been added. The ports of the district are scattered along 90 miles of natural and artificial waterway, all connecting with Sabine Pass. The deep-water ship canal which connects the ports of the district has a combined length of 53 miles. The first portion, 20 miles in length, runs from Sabine Pass and connects with the Neches River at its outlet into Lake Sabine. The second portion runs from the mouth of the Neches River to the mouth of the Sabine River as the Sabine debouches into the Sabine Lake. This portion is 8 miles in length. The third portion of the canal runs from the Sabine River just below Orange, Tex., to the Calcasieu River and is 25 miles in length. The towns of Sabine and Sabine Pass are situated on Sabine Pass; Port Arthur is situated on the deep-water canal, approximately 15 miles from Sabine Pass; Port Neches is situated on the Neches River, 25 miles from Sabine Pass; Beaumont is situated on the Port Neches River, approximately. 35 miles from Sabine Pass; Orange is situated on the Sabine River, 35 miles from Sabine Pass; Lake Charles, La., is situated on the Calcasieu River, approximately 75 miles from Sabine Pass. Three vessels entered the ports of the district with smallpox on board: The American schooner City of Portland from Miami, Fla., February 20, 1926, with two cases; the American tanker Aryan from New York, April 19, 1926, with one case; and the American tanker Gulfstream from New Orleans, April 26, 1926, with one case. The sick Men were isolated, all other persons vaccinated, and the vessels were disinfected .with formaldehyde permanganate. No secondary cases were reported. Port sanitary statements were issued as follows: 1. Showing compliance with provisional pratique: 534 Beaumont Port Arthur Sabine Orange 1,026 139 49 150 PUBLIC HEALTH SERVICE 2. Shdwing noncompliance with provisional pratique: Beaumont Port Arthur Inspections to ascertain compliance with provisional pratique: Port Arthur Beaumont Orange Port Neches 4 2 3,940 2,524 69 39 San Diego, Calif.—Surg. J. F. Worley in charge. Post-office address, Point Loma, Calif.; telegraphic address, San Diego, Calif. . One coastwise vessel entered port with a case of smallpox on board. The sick man applied at the relief station for treatment and was sent to the isolation hospital. The longshoremen who had been discharging the cargo of the vessel were vaccinated by the city health officer. The vessel was sent to the quarantine station, where the compartments occupied by the patient were disinfected and all of the crew were vaccinated. As all but 8 of the crew showed immune reactions within 72 hours, the vessel was remanded to San Pedro under provisional pratique. San Francisco, Calif.—Surg. R. H. Creel in charge. Post-office and telegraphic address, Angel Island, Calif. Seven vessels potentially infected with quarantinable diseases arrived at quarantine. Two of the vessels had leprosy on board and five had smallpox infection. The lepers were isolated at the quarantine station and later returned to the port of embarkation. Of the vessels infected with smallpox, one was from Europe by way of the Panama Canal, and the other four were from the Orient. The usual preventive measures, provided in the regulations, were applied against the smallpox-infected vessels. The sick persons, and those passengers and seamen who had been in contact with the sick, were isolaated at the quarantine station. Of the latter group, however, those who upon vaccination showed evidence of immunity were released. The utilization of the immune reaction as a means of releasing contacts at an early date proved to be of considerable advantage. When the station had advance notice of a case of smallpox on board an approaching vessel, the ship's physician was advised by radio to vaccinate contacts approximately 36 hours before arrival, so that it was possible to release a number of such contacts at the time of quarantine inspection. It is of interest to note that of the trans-Pacific passenger vessels the Japanese liners have been exceptionally free from smallpox infection, both among the crew and the passengers. This condition of affairs can very probably be ascribed to the enforcement of vaccination among crew and passengers on these vessels. In contrast to this, there has been in the past few years quite a number of infected American vessels from oriental ports. The subject was taken up with the shipping interests concerned, and more effective measures have been undertaken to prevent the development or extension of smallpox infection on board trans-Pacific liners. Routine vaccination is being performed on members of the crews by ghips' physicians, and stricter attention is being paid at the ports of embarkation by service representatives to the provisions of paragraph 108, United States Quarantine Regulations. In most of the cases of smallpox PUBLIC HEALTH SERVICE 151 developing on trans-Pacific vessels in recent years the infection has apparently been contracted at Hongkong or Shanghai, chiefly the latter port. Service operations at this port to prevent the introduction of plague have been carried on with the same activity as in former years. There were fumigated for the destruction of rats 514 vessels; 437 by. cyanogen-chloride, 50 by hydrogen-cyanide, and 27 by sulphur dioxide. A total of 1,837 rats was recovered as a result of the fumigations and delivered to the laboratory for autopsy. None was found to be infected. Of the rats killed by fumigation 902 were Mus alexandrinus, 920 Mus rattus, and 15 Mus norvegicus, 372 mice were also picked up, although no special attention was paid to the recovery of this species. The comparative absence of the Mus norvegicus on board vessels is in keeping with previous observations that the Norway rat is but rarely found on overseas shipping. Of the total number of rats recovered 1,080 were from the holds of vessels, 299 from storerooms, 58 from crews' quarters, and 390 from other superstructures, chiefly poop deck, lifeboats, and portable lockers for storing boat falls. Practically no rats were found in first-class passenger accommodations. Of the vessels fumigated approximately 280 were direct from plague-infected ports of the Orient or South America. The remainder of those fumigated were treated in accordance with the provisions of the quarantine regulations pertaining to periodic fumigation, or in conformity with outgoing quarantine restrictions in Oakland. In September, 1925, however, the restrictions against Oakland were discontinued. Of the total number of vessels fumigated no rats were recovered from 356. To some extent negative result was due to some of the vessels being partially cargo laden and thorough search not practicable. Of this group, however, a very considerable number was apparently rat-free, due, no doubt, to the repeated routine fumigation of regular line vessels entering San Francisco. Routine trapping of vessels was not practicable because of the lack of personnel, but an occasional vessel was trapped subsequent to fumigation as a means of checking the effectiveness of the fumigation. Trapping operations generally cover a period of three days, an average of 150 snap traps being used. On one vessel only were rats trapped subsequent to fumigation, four rats being taken in this manner after a fumigation that had destroyed 32 rats. It is thought possible that the surviving rodents had escaped destruction by hiding in deck structures or material. A liquid mixture of hydrogen cyanide and cyanogen chloride has been extensively used throughout the year with very satisfactory results. This method has an advantage over the "barrel method," in that it can be performed with less apparatus and with smaller personnel. The liquid product, however, is somewhat more costly than the generation of gas by the "barrel method." The impracticability of maintaining a large amount of liquid on the station, so as to be assured at all times of an adequate supply, is the one feature that militates against discontinuance of the "barrel method" of generating gas, and for this reason both methods are being used at the San Francisco quarantine station. 152 PUBLIC HEALTH SERVICE The provisions of the regulations to prevent the introduction of anthrax-infected shaving brushes have been carefully observed. PHYSICAL IMPROVEMENT Relations with other services on Angel Island and the San Francisco waterfront have continued to be marked by cordiality and spirit of mutual helpfulness. This station has been indebted to the Immigration Service for the transportation of passengers and freight from San Francisco, and in turn has been able to reciprocate through the loan of the quarantine 'steamer R. M. Woodward for the use of the Immigration Service when the regular immigration steamer was out of commission. On several occasions the buildings of the immigration station were fumigated for the destruction of vermin, more especially roaches and bed bugs'. The quarantine service at this port has also been indebted to the collector of customs for boarding facilities when the R. M. -Woodward was out of commission. There was also received valuable assistance from the near-by Army post, Fort McDowell. San Pedro, Calif.—Surg. H. A. Spencer in charge. One vessel, the American S. S. George Olsen, arrived at San Diego with a case of smallpox on board. The sick'man was removed at. that port, all personnel were vaccinated, and the vessel permitted to proceed to San Pedro. Those who had not shown immune reactions were revaccinate& and all but three were released. The British S. S. Empress of Scotland, which was making a round-the-world cruise, arrived at San Francisco with two cases of smallpox among the crew. The sick persons were isolated aboard, where they remained until after the departure of the vessel from San Pedro. Three passengers refused vaccination. Two were not allowed shore leave at this port and continued with the vessel. One disembarked under the supervision of the local health officer. So far as has been learned, no subsequent cases developed on either vessel. Classification, and location of rats recovered after fumigation of vessels Species Mus alexandrinus Mus rattus Mus norvegicus Mus musculus Holds 214 385 1 25 Living Peaks Provision and laza- quarters, storeroom rettes etc. 13 19 0 2 4 10 0 37 15 42 1 2 Total 246 456 2 66 The barge Disinfector, formerly used for storage, was sold at public auction on October 17, 1925. The hull of the launch S. D. Brooks was thoroughly overhauled and a new 45-horsepower full Diesel, 3-cylinder, 2-cycle engine was installed, a dependable boat resulting. 153 PUBLIC HEALTH SERVICE TEXAS BORDER STATIONS Quarantine transactions on the Texas-Mexican border for the fiscal year ended June 30, 1926 Brownsville Number inspected from interior Mexico Number of local passengers inspected Total number of passengers inspected Total number of persons disinfected Total number of persons passed without treatment Total number of persons vaccinated Total number of sick held for observation_ _ Total number of sick refused admission Total pieces of baggage disinfected 1,371 Del Rio Eagle Pass 2,270 3,076 El Paso 27,318 dalgo 2,023 Presidio Laredo 28,189 75 Rio Grande and Roma I 2,887 Total 67,205 853,503 110,167 763,886 2,445,375 28,115 1,070,330 12,617 34,853 5,318,846 854,874 112,437 766,962 2,472,693 30,138 1,098, 519 12,692 37,740 5,386,055 290 243 7, 178 40,351 36 10,762 0 850,892 111,280 759,784 2,414,939 29,776 1,060,259 12,496 126 58,986 33,232 5, 272,658 3,684 893 2,370 17,377 301 38,260 177 2,398 0 17 0 0 0 0 o 0 17 8 4 118 26 25 0 19 o 200 296 551 8,723 6,599 0 8,307 61 219 24,756 65,460 1 Two cases typhus at Rio Grande, Tex. El Paso, 77ex.-Surg. J. G. Wilson in charge. As heretofore, particular attention has been given to preventing the introduction of typhus fever and smallpox. Vaccination against smallpox is maintained constantly. The inspectors on duty on the international bridge are trained in vaccinating, and aliens who do not present evidence of immunity to smallpox are vaccinated. Although smallpox has been present constantly in Chihuahua and other Mexican States, whence many of the immigrants come, no cases of smallpox have been reported in El Paso during the past year. Four cases of typhus fever, which, however, could not be definitely traced to Mexico, were reported in El Paso during the spring of 1926. About 200 contacts, with their clothing, bedding, and other baggage, were disinfested at the service-disinfesting plant. Travelers who were obviously clean and not louse-infested were permitted to pass without bathing in the disinfesting plant, but persons who corresponded to the steerage class at seaports of entry were bathed, their clothing and baggage disinfected and, if necessary, they were vaccinated. The working people from Juarez termed "locals' were required to bathe once each week. Bath certificates were issued by inspectors on duty in the bathhouse and taken up after eight days, a new one being issued after each disinfestation. Laredo, Tex. Acting Asst. Surg. Nat K. King in charge. The activities of this station have been directed principally against the introduction of smallpox and typhus into the United States. In order to carry on the work of delousing the persons and clothing of travelers who have been found to be infested, a new disinfesting plant, situated at the international foot and wagon bridge, was leased. Five hundred or more persons can be disinfested daily without interfering with the regular inspection of travelers. 14656-26 11 154 PUBLIC HEALTH SERVICE Since no case of yellow fever had been reported from Mexico during the past year, the stegomyia control work was discontinued on June 30, 1926. At present, the stegomyia index in Laredo is so low that it is probable that ygllow fever would not spread even if a case should be imported. Presidio, Tex.—Acting Asst. Surg. C. M. Hatcher in charge. The hot-air sterilizer added to the station equipment during the year is a great improvement over the box formerly used for disinfecting baggage with formaldehyde. Rio Grande and Roma, Tex.—Acting Asst. Surg. C. J. Martin in charge. Hot-air sterilizers, which were installed at both Rio Grande City and Roma, have been used to good advantage. One case of leprosy and two of typhus fever, which had developed in Starr County, Tex., were diagnosed and turned over to the county health officer. The spread of smallpox from Camargo, Mexico, where it was epidemic, to the United States was successfully resisted. TRANSACTIONS AT INSULAR QUARANTINE STATIONS Summary of transactions at insular stations for fiscal year ended June 30, 1926 Aguadilla, P. R Ahukini, Hawaii Arecibo, P. R Arroyo, P. R Cavite, P.I Cebu, P.I Central Aguirre, P • R Christiansted, Virgin Islands Davao, P.1.1 Fajardo, P. R Frederiksted Virgin Islands Guanica, P. R Hilo, Hawaii Honolulu, Hawaii Humacao, P. R Iloilo, P.1 Job, P.I Kahuli, Hawaii Koloa, Hawaii Lahaina, Hawaii Legaspi, P.I.1 Mahukana, Hawaii Manila, P.I Mayaguez, P. R Olongapo, P.I Ponce, P. R St. Thomas, Virgin Islands San Juan, P R Zamboanga, P.I ,_ ' Vessels inspected Vessels fumigated 5 2 0 10 28 94 0 16 18 16 40 174 25 595 26 39 40 17 4 6 3 3 854 31 1 144 258 383 36 0 0 2,868 Total Passengers and crew inspected 0 0 0 234 0 0 58 51 0 107 4,264 9,533 0 125 Bills of heath issued 25 0 29 23 13 267 17 0 0 0 2 21 50 0 4,428 149,684 274 7,573 4,990 549 104 222 126 68 133,969 407 44 4,125 12,336 25,129 5,056 25 230 0, 37 0 21 35 189 73 0 0 0 3 0 970 36 1 72 0 775 139 696 378,414 2,980 0 0 0 3 4 36 0 121 0 0 0 0 0 0 225 1,608 102 2,536 10,946 1 Recently made a port of entry. REPORTS FROM INSULAR QUARANTINE STATIONS OPERATIONS OF THE SERVICE IN HAWAII Surg. Hugh de Valin, chief quarantine officer. Post office and telegraphic address, Honolulu, Hawaii. Only one quarantine station is maintained in the Hawaiian Islands, that at Honolulu, but vessels are inspected at the subports of Hilo, Mahukona, Koloa, Ahukini, Lahaina, and Kahului. PUBLIC HEALTH SERVICE • SMALLPDX 155 MEASURES As anticipated, the avirulent type of smallpox which had prevailed in the Pacific Coast States for some time, assumed during the winter months a more serious aspect, the disease attaining a mortality of 20 per cent in the city of. Los Angeles, where over a thousand cases were recorded between January 1 and June 1. Regulations requiring the vaccination of passengers and crew embarking for Hawaii were put into effect on April 5, 1926, and were continued until June 17. Similar regulations had been in force during the 1925 epidemic, their enforcement devolving upon the surgeons of the various steamships. The results at that time were not all that could be desired. In the hurry of departure it was found difficult to vaccinate, and quite naturally it was found equally difficult to examine and vaccinate passengers during the first two or three days •of the voyage. As a consequence, most of the vaccinations were performed shortly before arrival at. Honolulu, thus affording the community but little protection. A more satisfactory arrangement was made for the enforcement of the regulations during the present fiscal year. Prospective passengers, before purchasing their tickets at the ports of San Francisco, Los Angeles, Seattle, and Vancouver, were referred by the steamship companies to service officers, where the necessary inspections were made and certificates of immunity issued, vaccination being performed when indicated. With the adoption of this system passengers were immunized prior to arrival, and the occasional misunderstandings which had arisen under the old system were avoided. That the enforcement of reasonable vaccination regulations, coupled with careful inspection at quarantine, has achieved results is borne out by the fact that no case of smallpox has developed in Hawaii in the past several years, although as many as 30 cases have been detected at quarantine or have occurred on vessels en route to or from the islands. Smallpox was reported as follows: The S. S. Carinthia, on an around-the-world cruise, developed a case prior to arrival at Yokohama in the person of a first-class passenger, who probably had contracted the infection ii California. Similarly, a member of the crew of the S. S. Manoa departing from Honolulu on December 16 became ill the day of departure, and the case was diagnosed smallpox upon arrival at the San Francisco quarantine station, the infection almost certainly having originated in California. On the S. S. Empress of Scotland, subsequent to sailing from Honolulu, two mild cases developed, the contacts being handled at San Francisco. On the S. S. Sierra, arriving from the latter port on April 13, an unvaccinated cabin passenger became ill with confluent smallpox, necessitating the detention of 25 contacts until evidence of immunity could be obtained. On November 26, upon the arrival of the S. S. President Lincoln in port, the immigration authorities discovered 11 Chinese stowaways on board. These men were landed without quarantine inspection. The following day one of the stowaways, who probably had been ill for several days, was referred to the Queen's Hospital for treatment. Upon admission the hospital staff noted the presence of a petechial rash in the groins and axillee, but its significance was 156 PUBLIC HEALTH SERVICE left undetermined. Death occurred six hours after admission. A diagnosis of hemoirhagic smallpox (purpura variolosa) was immediately made and was confirmed by post-mortem examination. Energetic measures were at once instituted, and all possible contacts, fortunately few in number, were located and vaccinated. No secondary cases developed. PRECAUTIONS AGAINST CHOLERA The occurrence of cholera at Manila, Shanghai, Kobe, and Yokohama during the summer and fall months was the occasion for renewed vigilance at this port. The institution of outgoing quarantine measures, particularly at Manila and Yokohama, assured this station of some degree of safety, but considerable anxiety was felt over the possible introduction of a carrier. During the height of the epidemic shore liberty was denied steerage passengers and crews at foreign ports, and representatives of the service certified to the precautionary measures exercised. The rather low incidence of the disease at Asiatic ports, the close supervision exercised by the sanitary authorities, and the satisfactory conditions upon arriving vessels, were elements which precluded the necessity for the detention of vessels and the bacteriological examination of the personnel at this port, although had such a course been adopted, the margin of safety would have been greater. The fact that cholera carriers were detected at Kobe, Nagasaki, and Yokohama, on vessels from Chinese ports, and that the outbreak of the disease at Kobe and Yokohama was probably traceable to pollution of the harbor waters by undetected carriers, would seem to justify rigid precautionary measures elsewhere, even when such measures are accompanied by some delay and inconvenience to shipping. The majority of the cases of cholera at Japanese ports appeared among those in close contact with the harbor, water front, and beaches. The geographical and occupational incidence of the disease was such that the sanitary authorities were agreed that the harbors had been seeded by carriers, and that the eating of products of these waters, particularly in an uncooked state, was the main responsible cause. In this connection attention is invited to the possibility of introducing cholera into Honolulu in the same manner, although the size and conformity of the harbor are such that pollution of beach areas from vessels in the harbor is somewhat less likely than at certain other ports. However, there would be danger of pollution from the quarantine station, if cholera contacts should be detained. The sewage of the station, following septic-tank treatment, is discharged upon the reef, whence it is distributed over the contiguous tidal flats. These flats are a favorite fishing resort, and the products obtained, principally crabs, are usually eaten raw. That this danger is not wholly theoretical is borne out by the cholera epidemic of 1895, which originated in this manner. On the afternoon of August 9 of that year, the S. S. Belgic arrived at Honolulu 12 days from Yokohama, the steerage passengers, 542 in number, being remanded to quarantine for detention. Isolation of the passengers was complete, but on the morning of August 20, two PUBLIC HEALTH SERVICE 157 cases of cholera appeared among women of the city who had gathered crabs from the tidal flats adjoining the station. Altogether 84 cases of cholera, with 64 deaths, resulted in the city from the infection thus introduced. FUMIGATION OF VESSELS A total of 40 vessels were fumigated during the year, 36 at Honolulu and 4 at Hilo. Four of the fumigations were of single compartments, one of which had been occupied by a smallpox patient, and the others by lepers. Fumigation for rats was done on 14 vessels, from which 291 rodents were taken. Two vessels arriving at Hilo from South America were fumigated for mosquitoes. The remaining 20 were vessels of the Army, Navy, and Coast and Geodetic Survey, fumigated at the request of Government departments for the destruction of vermin. OPERATIONS OF THE SERVICE IN PORTO RICO Surg. 0. H. Cox in charge. Post office and telegraphic address. San Juan, P. R. Toward the close of the fiscal year, a survey of the fleas infesting the rats of Porto Rico was begun. It is hoped to complete this survey during the next fiscal year. The practice of fumigating cargoes of crated onions, potatoes, and similar products from the Canary Islands, the Azores, and other plague-infested territory has been continued. OPERATIONS OF THE SERVICE IN THE VIRGIN ISLANDS Surg. J. R. Hurley, chief quarantine officer. Post-office and telegraphic address, St. Thomas, V. I. Imaddition to the principal office and detention station maintained at St. Thomas, there are two boarding stations operated on St. Croix, Virgin Islands. One at Frederiksted, in charge of Lieut. Roger A. Nolan (M. C.), United States Navy, and one at Christiansted, in charge of Lieut. H. E. Robins (M. C.), United States Navy. Both of these officers cooperate with the chief quarantine officer in all matters relating to quarantine procedures. No quarantinable diseases have been encountered at any of the Virgin Islands ports during the year. Smallpox, called alastrim was reported unduly prevalent in certain islands of the French West Indies during the latter part of the year. Vaccination against smallpox was practiced at St. Thomas upon all arrivals from the French West Indies during the last three months of the year, also a campaign of vaccination was instituted in St. Thomas. The naval sanitation department vaccinated 736 school ehildren, and the Public Health Service vaccinated a few persons presenting themselves at the quarantine office, and furnished the Navy with a quantity of vaccine virus to enable them to promptly complete their work. A total of 43 persons were vaccinated by the quarantine service during the year. 158 PUBLIC HEALTH SERVICE OPERATIONS OF THE SERVICE IN THE PHILIPPINE ISLANDS Surg. H. F. Smith, chief quarantine officer. Post-office address, P.0. Box 424, Manila,P. I.; office, customhouse, Manila; telegraphic address, quarantine, Manila. Stations for the inspection of arriving and departing vessels are maintained at all Philippine ports of entry. The ports of entry at present are Manila, Cebu, Davao, Iloilo, Job, Legaspi, and Zamboanga. Quarantine officers are continuously on duty at all of the ports named, but only at Manila, Cebu, and Iloilo are there full-time quarantine officers. At Zamboanga, Job, Davao, and Legaspi local physicians are employed as quarantine officers on a fee basis. At Cavite and Olongapo medical officers of the United States Navy act as quarantine officers in addition to their other duties, being detailed for this duty by the admiral commanding the Asiatic Naval Station. DISEASES AFFECTING THE PHILIPPINE ISLANDS The Philippine Islands are, figuratively speaking, the hub of a half wheel, the spokes radiating to the ports of China, Japan, India, Borneo, Indo-China the Straits Settlements, Java, and other islands of the East India Archipelago to the south. Many of the ports of these various countries are within a comparatively short steaming distance of the islands, so that the presence or absence of quarantinable diseases in the territory contiguous to the Philippine Islands is of great concern to the quarantine officer. The proximity of many of these ports, often foci of infection of epidemic diseases, constitutes a serious problem and increases the difficulty of the quarantine procedure in the Philippines. This is due to the fact that persons may leave adjacent infected ports and arrive in the Philippine Islands long before the incubation period of many of tdhe quarantinable diseases has passed. As an instance, an individual may be exposed to smallpox in Amoy, arrive in Manila three or four days later and spend eight or ten days in the Philippines before the disease can be detected. When it is considered that the incubation period of cholera is approximately five days and that of plague seven days, and that the sailing time between the Philippines and several infected foreign ports is less than three days the difficulty of successful quarantine may be better appreciated. On account of this factor the appearance of plague, cholera, typhus fever, or other epidemic disease in any of the near-by ports is always a cause of great anxiety to the quarantine service in the Philippines. At no other place where the United States Government maintains quarantine does such a condition exist. Practically every other quarantine station under the United States jurisdiction is a considerable number of days distant from infected ports. As a result quarantine activities in the Philippines take on a more vital and important character than at those ports where the time element is .a positive and continual protection and where, with the longer intermediate voyage, almost all of the quarantinable diseases develop to a point where they can be readily detected at quarantine inspection. Sporadic cases of nearly all of the quarantinable diseases occurred in various ports of the Orient, but in only a few cases did these diseases assume epidemic proportions. Fortunately, with the exception of Amoy, Saigon, and several Indian ports, the Orient remained comparatively free from human 159 PUBLIC HEALTH SERVICE plague. Smallpox occurred almost continuously, but in only a few places did it assume epidemic proportions. Cholera was quite widespread and virulent in certain districts. QUARANTINE AGAINST AMOY Because of an outbreak of bubonic plague at Amoy, China, it was decided to declare a quarantine of seven days, dating from the time the vessel left Amoy,effective May 24, 1926. During the period from that date to the close of the fiscal year four vessels, carrying 204 crew and 1,014. passengers, were detained. No quarantinable diseases occurred among the persons detained. QUARANTINAI3LE DISEASES IN THE PHILIPPINE ISLANDS The presence or absence of quarantinable disease within the Philippine Archipelago is an important factor in determining the quarantine measures to be imposed on vessels bound for American ports. On the whole, conditions in the islands with regard to quarantinable diseases have been very favorable during the past year. On June 20, 1925, one case of cholera was reported in the city of Manila. This was followed by a few sporadic cases, a total of 23 cases with 5 deaths having been reported up to the third week of September. During the week ended September 19 a considerable increase was observed, seven cases being reported. During the next 14 days 155 cases with 50 deaths occurred in the city. From that date the epidemic gradually subsided, and only a few isolated cases have been reported since November 14, 1925. A total of 313 cases with 138 deaths were reported. In the Provinces several localities reported cases of cholera, but no widespread or severe epidemic occurred during the year. The distribution was as follows: Bataan Batangas Bohol Bulacan Camarines Sur Capiz Laguna Leyte Manila Mindoro Cases Deaths 20 16 20 506 1 1 30 4 313 99 18 13 15 298 0 1 16 4 138 76 Mountain Province Mueva Ecija Pampanga Rizal Romblon Surigao Zambales Cases Deaths 1 5 117 244 83 1 1 1 4 102 83 68 1 1 1,462 839 As soon as cholera assumed a tendency to increase this office required the examination for cholera vibrios of the stools of all persons of the steerage class leaving Manila for other American ports. The examinations made by months were as follows: Month July August September October November December 1925 Examinations made 378 416 677 874 392 392 Positive for cholera 0 7 9 8 4 1 Month January February March April May June 1926 Examinations made Positive for cholera 591 805 1,028 1,484 1,288 1,205 5 8 23 12 7 5 9,530 89 160 PUBLIC HEALTH SERVICE So far as known, no human plague occurred in the Philippine Islands during the year nor were any plague rats found in the course of routine examinations at the Bureau oeScience. Smallpox has become a negligible disease, temporarily at least, as a result of vaccination. Most of the Provinces of the Philippines did not report a single case of this disease during the year and only a few sporadic cases were reported from the Archipelago. Neither typhus nor yellow fever was detected in the islands. Leprosy is present continually. The law requires the reporting and segregation of every case of leprosy detected, but no statistics are available to demonstrate whether or not the continuous segregation has actually diminished the number of new cases. To demonstrate the value of this measure would require a knowledge of all the cases which were existent when the policy of segregation was commenced, as well as the number of existing cases to-day, many of which are of an obscure nature. SMALLPDX AND VACCINATION During the latter part of the year under report smallpox occurred on several vessels bound for ports in the United States. Consequently, vaccination of all members of crews of vessels bound for American ports was required. Steerage passengers were required to present a certificate of vaccination against smallpox before purchasing tickets. Eight thousand eight hundred and thirteen seamen and 2,730 passengers were vaccinated. Continuing the work of previous years, an endeavor was made to have all persons employed on interisland vessels vaccinated, and inspection of these vessels was instituted to check up on the results. A. total of 4,641 of these persons, members of crews of interisland vessels, were vaccinated, either on board the vessels or in the quarantine office. An arrangement was made whereby no individual was permitted to sign on unless he could present a recent certificate of vaccination from the quarantine office. INCOMING QUARANTINE The chief concern of the Quarantine Service is the prevention of the introduction of quarantinable diseases by vessels. Consequently, incoming quarantine is the most important function of the service in the Philippines and one which demands most careful attention and the strictest vigilance. In addition to the routine inspection of arriving vessels, it was necessary, for a considerable period of time, to examine certain arriving passengers for cholera organisms, vaccinate crews and arriving passengers, and to detain in quarantine certain vessels arriving from infected ports. All steerage passengers for the Philippine Islands were required to undergo vaccination or to show that they had been recently successfully vaccinated before being allowed to land in the Philippines. From May 24, 1926, to the close of the fiscal year, owing to the presence of plague in Amoy, vessels from that port were required to complete seven days from the time of departure from Amoy before landing either passengers or crew in the Philippine Islands, and, in addition, to undergo fumigation prior to the discharge of any cargo. All arriving vessels were inspected to de. 161 PUBLIC HEALTH SERVICE termine whether or not they should be fumigated for the destruction of rodents, and the requirements prescribed were made a part of the provisional pratique which was issued on the arrival of the vessel. The amount of shipping arriving at Philippine ports compared favorably with preceding years. The figures in the statistical tables show the volume of work done. CONSULAR QUARANTINE All steerage passengers leaving the Philippines for American ports were required to be vaccinated or to produce evidence of a recent successful vaccination. Bills of health were issued at ports of entry in the Philippine Islands as follows: To United States ports Bills of health issued 449 2 157 13 141 Manila Cavite Cebu Davao Iloilo To foreign ports 521 11 110 12 48 Bills of health issued Jobo Legaspi Olongapo Zamboanga To United States ports 73 2 0 112 T? foreign ports 0 1 1 27 IN rtatISLAND QUARANTINE It was not necessary to impose quarantine detention on vessels engaged in plying among island ports except during a very short period in the latter part of 1925, during the cholera outbreak, when vessels from Manila were required to undergo quarantine inspection at the various island ports. Fortunately no cases of cholera are known to have been carried from Manila to other ports in the Philippine Islands by vessels. On two occasions interisland craft were reported as having cholera on board. Both of these vessels were remanded to the quarantine station at Cebu for treatment. One of these cases was bacteriologically positive and the other negative. One interisland vessel coming from the port of Romblon was quarantined at the port of Manila on arrival, owing to a sharp increase in the number of cholera cases which had occurred at Romblon, and on bacteriologic examination of stool specimens of the personnel of the vessel 11 cholera carriers were found. Bills of health were not required for interisland vessels at any port of entry during the year. All interisland vessels were required to undergo fumigation not less than once each six months. As noted previously, the crews of interisland vessels were required to be recently vaccinated, and each new member of the crew not possessing a recent vaccination card issued by the quarantine service was revaccinated prior to being employed. Interisland vessels were permitted to enter and leave port without other restriction than filing a certificate that no cases of suspicious illness had occurred on board during the five days previous to entry. All vessels in the interisland trade were inspected at least twice during the year. 14656-26 12 162 PUBLIC HEALTH SERVICE EQUIPMENT One of the necessities of quarantine work is water transportation. The maintenance and operation of launches and boats in the Philippine Islands always constitute a difficult problem. The rapid deterioration of wood and metal in this climate, plus the action of sea water, the continuous bad weather during a large portion of the year, resulting in accidents in boarding ships, produce a condition in connection with floating equipment IAThich is always trying. Practically all of the funds appropriated for general repairs were expended in repairing launches. The legislature appropriated funds during the year for the purchase of another launch, and a secondhand launch in excellent condition was purchased in June, 1926, to replace the launch at Iloilo, which had to be condemned. The buildings at the several quarantine stations were kept in fair repair. It was necessary to tear down the two-story cabin barracks at the Mariveles quarantine station because it had become unsafe. Efforts are being made to secure an appropriation to replace that building, but under present circumstances it is doubtful if funds for this purpose will be made available. The equipment of the stations is diminishing annually, since it has been impossible to replace that which has been condemned. Two new ports of entry have been opened (Davao and Legaspi), but so far no quarantine equipment has been obtained for either of these new ports. AIRCRAFT There is practically no traffic to and from the Philippine Islands by means of aircraft from foreign countries. Pratique, however, was granted to two of the airplanes which arrived in the Philippines, one from Italy and one from Spain. Bills rendered for quarantine services .at maritime stations during the fiscal ;year ended June 30, 1926 • Station Aberdeen, Wash. 1 Atchafalaya (Morgan City), La Baltimore, Md Beaufort, S. C Boca Grande, Fla Boston, Mass Brunswick, Ga Cape Fear (Southport), N. C Cedar Keys, Fla Charleston, S. C Columbia River (Astoria), Oreg Coos Bay, Oreg Cumberland Sound (Fernandina), Fla_ _ Delaware Breakwater, Del Eastport, Me Eureka, Calif Fall River, Mass Fort Bragg, N. C Fort Monroe, Va Freeport, Tex Galveston, Tex " Georgetown, S. C Gloucester, Mass Onlf -Mice 1 Formerly Hoquiam, Wash. Inspections of vessels Fumiga• tons of vessels $750. 00 0 7, 175. 00 0 262. 00 12,047. 00 215. 00 442. 00 0 1,657. 00 1,310. 00 180. 00 80.00 52. 50 0 105.00 485. 00 0 7,453. 00 1,060.00 6, 396. 00 20. 00 0 MA 00 0 0 $31,326. 56 0 483.60 15, 828. 97 122. 73 1,002.80 0 1, 523.62 6, 162. 79 170. 00 59.43 0 0 116. 20 0 0 18, 577. 75 0 7, 811. 62 0 0 1_299 77 Subsistence furnished to ships 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 n Miscellaneous quarantine services 0 0 $12. 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 153. 00 0 0 0 0 In nn Total $750. 00 0 38, 513. 56 0 745. 60 27, 875. 97 337. 73 1,444. 80 0 3, 180. 62 7,472. 79 350. 00 139.43 52. 50 0 221.20 485. 00 0 26, 183. 75 1,060. 00 14, 207. 62 20. 00 0 1.772.77 163 PUBLIC HEALTH SERVICE Bills rendered for quarantine services at martime stations, etc.—Continued Inspections of vessels Station Hawaii facksonville, Fla.2 Ketchikan, Alaska Key West, Fla_ Marcus Hook (Philadelphia), Pa Miami, Fla.3 Mobile, Ala Monterey, Calif New Bedford, Mass _ New Orleans, La Newport, Oreg Newport, R. I New York, N. Y Ogdensburg, N. Y Pascagoula, Miss Pensacola, Fla Perth Amboy, N. J Port Angeles, Wash Port San Luis, Calif Porto Rico Portland, Me Port Townsend, Wash Providence, R. I Sabine, Tex St. Andrews, Fla St. George Sound, Fla St. Joseph, Fla San Diego (Point Loma), Calif San Francisco, Calif San Pedro, Calif Santa Barbara, Calif Savannah, Ga Seattle, Wash South Bend, Wash Tampa, Fla Vineyard Haven, Mass Virgin Islands Washington, N. C West Palm Beach, Fla.4 2 3 4 Subsistence furnished to ships Miscellaneous quarantine services Taal 520. 54 9,273. 00 1,430.62 1,390. 00 0 0 69. 24 3,603. 00 35,895. 77 11, 120. 00 0 2.998.00 7, 140. 87 3, 779. 00 0 0 0 170. 00 14,629.90 27, 663. 00 0 0 0 10. 00 42,665. 00 167,069. 93 0 0 45. 00 200. 00 3, 090. 08 994. 00 901.84 370.00 0 0 0 00 90. 808. 98 7,020. 50 3, 284.67 1,655. 00 2, 308. 85 4,841. 00 38. 72 1, 235. 00 4, 716. 93 3, 306. 00 07 193. 100. 00 0 0 0 0 106. 46 2,401. 00 42,984. 69 6, 196. 00 12,802. 54 9,573. 00 0 0 1, 153. 87 1,560. 00 52 11,802. 0 9. 00 90. 00 68 218. 3, 2, 430. 00 0 12. 00 61. 96 3,058. 26 0 0 0 0 $724. 00 0 0 0 0 0 0 0 0 147. 00 0 0 71. 13 0 0 8. 00 0 0 0 0 0 69. 00 0 0 0 0 0 0 188. 00 0 0 0 0 0 0 0 0 0 , 0 61. 75 0 0 0 . 25 0 0 0 434. 00 957. 02 0 0 24, 136. 50 0 0 0 0 0 0 512. 00 0 0 0 19. 50 0 0 0 6. 25 0 2. 00 0 0 0 0 0 0 7. 00 0 0 10, 579.29 2,820. 62 0 3,672. 24 47,016.02 2,098.00 10,919. 87 0 604. 00 43, 396. 92 0 10.00 233,942. 56 0 245. 00 4, 092. 08 I, 271. 84 0 90. 00 8,341. 48 4,939.67 7, 218. 85 1, 273. 72 8,042. 43 293.07 0 0 2,513. 71 49,368. 69 22, 377. 54 0 2, 713. 87 11,802. 52 99. 00 8, 648. 68 12. 00 3, 127. 22 0 0 398,693. 57 1,207. 13 26,311. 27 614, 244. 23 188,032. 26 Total Fumigations of vessels Formerly St. Johns River, Fla. Formerly Biscayne Bay, Fla. opened Apr. 1, 1926. TRANSACTIONS AT FOREIGN PORTS Summary of transactions at foreign ports Stations Vessels inspected Vessels fumigated Passengers and crews inspected Bills of health countersigned Amoy, China Guantanamo Bay, Cuba Guayaquil, Ecuador Habana, Cuba Hongkong, China Progreso, Mexico Puerto Mexico, Mexico Shanghai, China Tampico, Mexico Tuxpam and Port Lobos, Mexico Vera Cruz, Mexico Yokohama, Japan 27 6 151 2, 126 378 259 0 387 1,646 12 348 300 0 0 0 240 33 14 1 136 445 0 125 51 15,918 0 13,662 259,252 98,775 13, 261 0 25,357 11,473 570 19, 171 61,358 43 265 201 2, 126 488 259 60 651 1,646 12 348 745 Total European ports 5,640 1, 134 1,045 802 518, 797 336,264 6, 774 1,847 855,061 6,844 5,962 ---12, 806 Total 164 PUBLIC HEALTH SERVICE REPORTS FROM FOREIGN PORTS SERVICE OPERATIONS IN EUROPE Paris, France.—Surg. W. W. King in charge. The quarantine operations of the service in Europe have continued along the same lines as in previous years, attention being paid chiefly to the inspection of third-class passengers and those of the same type traveling second class. The sanitary standard of this type of passenger has materially improved during the past few years, largely as a result of the enforcement of sanitary measures by Public Health Service officers at foreign ports. The institution of medical examination prior to granting consular visas to persons going to the United States has caused a still further improvement in passengers coming from countries where such examinations have been made. • The higher standard of personal hygiene of the passenger, with the continued improvement of health conditions in Europe, have permitted some modification of the measures applied at European ports to passengers embarking for the United States. It has been possible to make these measures less rigorous in regard to vaccination against smallpox, delousing of persons, and disinfection of baggage. The routine application of sanitary measures to persons of steerage type from certain countries has been discontinued, but it is still in force in regard to persons of this type from certain other countries whose health conditions, although improved, do not yet warrant the discontinuance of general application of the sanitary measures. Vaccination is still required for persons coming from districts where smallpox prevails in epidemic form, and persons from countries where typhus fever prevails must undergo the measures directed against vermin infestation. Passengers of the third-class type from all Europe are inspected and are subjected to sanitary measures if the inspection shows that such measures are required. The modifications in the sanitary regulations were made during the last quarter of the fiscal year and had proportionately small effect upon the statistics for the whole year, which show approximately the same numbers as those of the previous year. The Public Health Service officer detailed at Belfast, Ireland, primarily for the medical examination of persons applying for consular visas, has also exercised supervision of the application of the quarantine measures to vessels and persons leaving that port for the United States, and Belfast appears for the first time on the statistical table. On the other hand, the supervision of such measures by Public Health Service officers has ceased at the following ports: Marseille, France, October 17, 1925; and Havre, France, April 30, 1926. SANITARY CONDITIONS IN EUROPE General health conditions in Europe and those portions of Asia and Africa from which travel to the United States comes via Euro- PUBLIC HEALTH SERVICE 165 pean ports has maintained the reasonably good state of the previous years. Plague continues to be endemic in the Canary and the Madeira Islands and in Egypt. Occasional cases have been reported from Constantinople, Beirut„ and other Mediterranean ports. More important outbreaks have occurred at Athens and Pirus, with sporadic cases occurring in other parts of Greece; at Kairwan, Tunisia, and in the extreme southeastern districts of European Russia. Typhus fever continues prevalent in Russia and Poland, but less than in previous years. Lithuania, Rumania, Yugoslavia, and Czechoslovakia constantly report the presence of this disease in widely scattered localities, except the latter, where the disease seems to be confined to the extreme eastern part of the country. Morocco, Tunisia, and Egypt have reported outbreaks, and occasional cases are reported from Algeria. A small outbreak at Naples, Italy, during February and March was promptly controlled. Smallpox has been specially prevalent in England, where the number of cases has reached epidemic proportions at times in some, districts, although the type of the disease is very mild. In Spain the malignant type of the disease continues. Epidemics have occurred in Algeria, Tunisia, and Egypt. An outbreak at Paris, France, occurred during the winter. Russia and Poland have reported an unusually low incidence of the disease. MISCELLANEOUS OPERATIONS The service officers in Europe supervise the fumigation for deratization of vessels bound to the United States when the quarantine regulations require that measure. Other operations have included the collection and transmission of sanitary information, medical examination, and treatment of American seamen, beneficiaries of the Veterans' Bureau, etc., and valuable service has been rendered by advice given consular officers upon medical questions which frequently arise in the course of official matters. INTERNATIONAL MEDICAL CONFERENCE Surg. W. W. King was detailed as the delegate of the Public Health Service at the International Malaria Congress held at Rome, Italy, October 3-5, 1925; as delegate of the United States on the Permanent Committee of the International Office of Public Hygiene, which met at Paris, France, October 19-29, 1925, and May 3-13, 1926; and as one of the delegates of the United States at the International Sanitary Conference held at Paris, France, May 10—June 21. Surgeon Hooper was detailed to represent the Public Health Service at the Fourth International Conference on Industrial Accidents and Diseases held at Amsterdam, the Netherlands, September 5-12, 1925. 166 PUBLIC HEALTH SERVICE Report of service operations in Europe, fiscal year 1926 Place Antwerp, Belgium Barcelona, Spain Belfast, Ireland Bordeaux, France Bremen, Germany Cherbourg, France Cobb, Irish Free State Danzig, Free City Genoa, Italy Glasgow, Scotland Hamburg, Germany Havre, France Libau, Latvia Liverpool, England London, England Londonderry, North Ireland Marseille, France !laples, Italy Patras, Greece Pirmus, Greece Rotterdam, Holland Southampton, England Baggage Vessels Baggage inspected Vessels ,,,rui_ without disininspected gated disinfected fection 1,833 215 9 5, 194 19 10 6,004 16,008 11, 130 20,471 5,495 10,066 1,755 9,282 856 1,062 29 67,282 7,243 1,193 6,567 3,469 4,095 196 13 36 27,286 1,111 3,109 3,517 1, 156 111,720 Total Place Antwerp, Belgium Barcelona, Spain 1 Belfast, Ireland 2 Bremen, Germany Cherbourg, France Cobh, Irish Free State Danzig, Free City Genoa,Italy Glasgow, Scotland Hamburg, Germany Havre, France, Libau, Latvia Liverpool, England London, England Londonderry, North Ireland Marseilles, France 4 Naples, Italy Patras, Greece Pirmus, Greece_ Rotterdam, Holland Southampton, England TotaL Medical Bills of examinahealth tions of counter- service benefisigned ciaries 870 91 58 96 24 94 5 74 1 2 101 39 227 63 174 88 39 346 45 47 1, 745 389 85 26,617 340 994 3,787 7 167 31 69 26 60 2 410 564 27 53 269 31 84 712 438 137,948 1, 134 802 5,962 43 55 1 23 1 331 356 193 28 285 259 682 221 2 8 163 1 40 25 3 194 13 35 1 499 PasPasPasPasPasCrew Crew sengers Crew sengers sengers • sengers sengers devacelinrededein- spected vacci- nated loused tamed jected loused nated spected 6,425 304 202 39,814 47,517 26, 755 22,188 9,656 16,623 37,861 15,800 5,349 14,838 2,401 2,595 68 32,330 960 3,932 7,810 23,227 316,655 329 3 755 52 9,604 3,975 4,891 4,666 48 9 15,879 20,811 17,210 10,932 6,105 9,183 13,804 4,509 2,206 2,104 254 1,039 66 32,330 960 3,839 3,062 12,263 19,609 159,279 1,228 1,406 13 6,130 16,244 17,102 20,483 5,487 66 3,234 2,416 2,661 48 1,015 1 57 418 10 22,823 674 3,589 2,405 848 83 1,128 107,024 141 157 28 895 3,909 9,028 68 1 3 1,648 1, 920 13 22 9 67 1,237 35 4 48 19,088 152 1 Operations ceased Dec. 31, 1925. 2 operations began Aug. 1, 1925. Operations ceased Apr. 30, 1926. 4 operations ceased Oct. 17, 1925. NOTE.-Reasons for rejection: Vermin infested, 75; fever, 9; measles, 1; to complete observation period after delousing, 32; other members of families of detained persons, 5; immigrants booked as special thirdclass tourists, 8. AMOY, CHINA Acting Asst. Surg. E. J. Strick in charge. All passengers for the Philippines were vaccinated against smallpox. At first this vaccination was done at the time of sailing, but at the beginning of 1925, with the advice and cooperation of the chief 167 PUBLIC HEALTH SERVICE quarantine officer, a new system was instituted. The steamship companies supply the prospective passengers with cards to which the passenger's photograph is attached. The passenger comes back for daily inspection until his immunity is established and he is then released. The steamship companies are warned not to allow any passengers on board unless they have been released. GUAYAQUIL, ECUADOR Acting Asst. Surg. Carlos V. Coello in charge. Plague.—One hundred and twenty-four cases of plague, with 54 deaths, occurred in Guayaquil and vicinity during the calendar year 1925. This is 30 cases and 11 deaths more than during the previous year, although the measures carried out by the local health authorities have been enforced with the usual activity. Deratization has been active. According to official information 269,190 rats were trapped be infected with plague. during 1925, 1,165 of which were found to' Plague appeared this year in Ambato, 318 kilometers from Guayaquil and 2,608 meters above sea level, where 4Q cases were reported, causing considerable concern in that region, especially Quito (146 kilometers north of Ambato). After a few weeks of intensive work (vaccination, isolation, and deratization) the disease apparently disappeared. This is not the first time that Ambato has been visited by the plague; in 1915, 11 cases and in 1921, 7 cases were reported. Smallpox.—Only 1 case was reported, with no death, against 6 cases reported during the previous year. During the same time 5,959 persons were vaccinated by the local public-health service. Passengers booked from this port for the Canal Zone or ports of the United States, as well as those in transit from Peru and Chile, were required to show evidence of recent vaccination for smallpox. Intense vaccination is responsible in part, at least, for the abatement of this disease. HABANA, CUBA Acting Asst. Surg. Richard Wilson in charge. The transactions at Habana are shown in the following table: Vessels going direct Vessels going via foreign ports Total bills of health issued Members of crews on vessels going direct Members of crews on vessels going via foreign ports Total members of crews Passengers embarking in Habana Passengers in transit_ Total passengers Passengers for the United States and its dependencies (included in the above) Vaccination certificates Vessels fumigated by the service Vessels fumigated by the Cuban quarantine under the supervision of the service Vessels recommended for fumigation at a United States port Increase 1924-25 1925-26 1,129 943 2,072 83,321 54,420 137,741 48,199 44,932 93,131 1,171 955 2,126 93,936 55,403 149,339 60,508 49,405 109,913 42 12 54 10,615 983 11,598 12,309 4,473 16,782 75,107 0 11 91,403 0 12 16,296 0 1 124 0 228 0 104 0 Or decrease 168 PUBLIC HEALTH SERVICE HONGKONG, CHINA Asst. Surg. F. J. Halpin in charge. On July 17, 1925, smallpox was discovered in a second-class passenger on the steamship Empress of Russia on arrival at this port from Shanghai en route to Manila. The sick person, with two other occupants of the same cabin, were removed from the ship and placed in quarantine. All passengers and crew were vaccinated by the ship's surgeon. The second-class cabins were fumigated by the colonial port medical authorities. At the time of inspection and sailing for Manila, P. I., July 18, at 5 p. m., there was no evidence of sickness on board. On March 15, 1926, a Filipino male steerage passenger from Manila en route to Seattle was removed from the steamship President Grant on arrival at this port upon cabled advice from the director, quarantine district of the Orient, that he was a cholera carrier. This passenger was transferred to the steamship President Monroe and returned the following day to Manila. He was placed in isolation in the ship's hospital. Twenty prospective Chinese passengers holding overdue laborer's return certificates issued by the Bureau of Immigration of the United States or of the Philippine Islands were sent to this office by the American consul general in order to ascertain, if possible, if their contention that they were unable to return to the United States or the Philippine Islands because of physical disabilities was justified. Effective June 5, 1925, a new system of vaccination for the prevention of smallpox among steerage passengers for the Philippine Islands was instituted. The system consists of the scratch method with single-scratch control. Steamship companies are advised not to sell tickets to prospective steerage passengers until the latter are passed by this office. The steamship company supplies a card upon which appears the name, address of last permanent residence, and photograph of the prospective passenger. The applicant is instructed to bring the card to a local physician on the approved list, who after vaccinating applicant affixes his name and the date. After 24 hours and each succeeding day the passenger reports to this office for observation until a "take" or "immunity reaction" is established. The card is then signed by the medical officer and impressed with the service seal. Upon presentation of this card at the steamship office the passenger is eligible to travel. The same procedure was inaugurated with reference to steerage passengers destined for the United States, effective April 1, 1926. YOKOHAMA, JAPAN Surg. V. B. Murray in charge. Yokohama may now be considered as having recovered from the effects of the earthquake and fire, especially in respect of dock construction and other public work. Although exposed to at least two formidable invasions of quarantinable diseases, the prefectural sanitary authorities, coordinated by the sanitary bureau of the home department, have at all times kept the situation well under control. 169, PUBLIC HEALTH SERVICE Cholera was present in the Tokyo Bay and Inland Sea region from late in August until the end of October, 1925. It appears that this infection was spread from shell-fishing grounds, which had been contaminated by shipping from south China. Special regulations against smallpox were put into effect in Yokohama February 22, 1926, and removed May 21, 1926. A total of 68 cases were. reported from the Prefecture in which Kokohama is situated. Preceding the epidemic persons infected with smallpox had been landed from vessels from the United States, Canada, and China, although it is probable that the infection was introduced from China. The strict enforcement of vaccination by the Japanese Government as a prerequisite to entering school and the revaccination of men when they are called up for military examination kept the number of cases down. October 31, 1925, the Far Eastern Association of Tropical Medicine met in Tokyo. This was the first international congress t& be held in Japan. Surg. H. F. Smith and Vance B. Murray represented the Public Health Service at this meeting. Annual medical examinations of the naval officers attached to the American Embassy in Tokyo were made on March 23, 1926. Kedani mites and snails were collected and forwarded to the hygienic laboratory. Sera from patients infected with Ohara's disease were forwarded to Surg. Edward Francis, who identified this disease as tularemia. Arrangements were made for the shipto ment of cultures of plague bacilli from Doctor Wu, of Harbin, co. Surg. N. E. Wayson at San Francis A special report on the occurrence of plague in Japan was prepared and forwarded to the bureau. SUMMARY OF QUARANTINE TRANSACTIONS and foreign staSummary of quarantine transactions at continental, insular, 1926 30, June ended year fiscal the for tions Station Number of vessels inspected Number of vessels fumigated Number of passengers and crews inspected Bills of health issued or countersigned Continental Insular Foreign 17,056 2,868 6,774 5,019 1 1,777,064 378,414 696 855,061 1,847 2,980. 12,806 Total 26,698 7,562 3,010,539 15,786 Statistics do not include "local" travelers at 1 Maritime stations, 1,709,855; border stations, 67,209. given cursory inspection. border stations, numbering 5,318,846, who, however, were MEDICAL INSPECTION OF ALIENS officers During the fiscal year there were examined by medical ers passeng alien 614,972 Service Health of the United States Public or diseases, defects mental or l physica ng detecti of purpose the for as compared as provided for in the United States immigration laws, 938,928 for 1925, 30, June ended year fiscal the for 545,472 with year ended, the fiscal year ended June 30, 1924, 745,515 for the fiscal 170 PUBLIC HEALTH SERVICE June 30, 1923, 586,228 for the fiscal year ended June 30, 1922, and 1,137,682 for the fiscal year ended June 30, 1921. In addition to the passengers examined, 872,842 alien seamen were inspected, as provided for in the act of February 5, 1917, as compared with 854,915 for the fiscal year ended June 30, 1925, 874,962 for the fiscal year ended June 30, 1924, 826,295 for the fiscal year ended June 30, 1923, 783,193 for the fiscal year ended June 30, 1922, and 851,928 for the fiscal year ended June 30, 1921. The reduction in the number of alien passengers examined in 1922 and subsequent years from that in 1921 was largely due, to the application of the "3 per cent law." The immigration act of 1924 further reduced the number of immigrants. The accompanying tables present in detail the data relative to the inspection and certification of alien passengers and alien seamen. EXAMINATION OF PROSPECTIVE IMMIGRANTS ABROAD A change in the method of handling prospective immigrants to the United States, of far-reaching importance, was inaugurated during the fiscal year. For many years the hardships necessarily entailed upon a certain number of would-be immigrants by their rejection at the ports of entry to the United States have elicited the sympathies of philanthropically inclined persons. More recently a steadily growing popular demand that measures be taken to mitigate or avoid the imposition of such hardships has become manifest. The passage of the immigration act of 1924, by authorizing American consular officers to withhold visas from persons ineligible to enter the United States, made it possible to comply with the growing demand for the examination of prospective immigrants in the countries of their origin previous to embarkation for the United States. About the beginning of the fiscal year it was decided by mutual agreement of the Secretaries of the State,Treasury,and Labor Departments with the British Government to conduct, for a period of three months an experiment to determine the feasibility of examining prospective immigrants in the country of origin. It was planned that medical officers of the Public Health Service and inspectors of the Bureau of Immigration would act as technical advisors in their respective lines to the consular officers who issue the immigration visas. In accordance with the plan on August 1, 1925, medical officers were detailed for duty at the _American consulates at Belfast, Cobh, Dublin, Glasgow, Liverpool, London, and Southampton. The advantages to the three classes of people directly concerned of having the prospective immigrants examined before embarkation are so obvious that the success of this experiment was practically assured before it was begun. The parties directly interested in the examination of immigrants are: (1) The people of the United States, (2) the immigrants, (3) the transportation companies. The advantages to the people of the United States are: The immigration laws are much more efficiently enforced when the prospective immigrants are examined by medical officers of the Public Health Service abroad. Up to date, all of the immigrants found to be afflicted with diseases mandatorily excludable under the law were refused visas by the consular officers. It is a matter of common PUBLIC HEALTH SERVICE 171 knowledge that only a part of the immigrants certified for mandatorily excludable diseases in ports of the United States are actually deported. Lack of funds, political influence, and a host of other factors operate to make deportation difficult or impossible. Also a considerable proportion of the aliens certified as afflicted with disease or disability liable to affect their ability to earn a living were refused visas. The fact that the examinations of prospective immigrants abroad are made according to schedule and by appointment makes it possible for them to be more thorough and painstaking as compared with the necessarily hurried examinations when large shiploads of immigrants arrive at United States ports. The advantage to the immigrant of being examined near his home and of being reasonably certain that he will not be denied admission to the United States before he has disposed of his goods and chattels and undertaken a tiresome and expensive journey is very great. It is obvious that the financial losses and heartaches necessarily entailed by rejection at the port of entry are greatly mitigated by rejection before departure. The substitution of refusing visas for rejection at the port of arrival is bound to reduce materially the number of fines imposed upon transportation companies for importation of aliens in violation of law. Transportation companies, the immigrants, officials of the State, Treasury, and Labor Departments, and the press, both foreign an domestic, are practically unanimous in approval of the plan. Because of the success of the experiment in Great Britain and Ireland, the examination of prospective immigrants has been extended to Antwerp, Belgium, and Rotterdam, the Netherlands, and it is expected that it will be introduced at Berlin, Bremen, Cologne, Hamburg, and Stuttgart, Germany; Copenhagen, Denmark; Bergen and Oslo, Norway; Warsaw, Poland; and Gothenburg and Stockholm, Sweden, early in the next fiscal year. ... <'-'''' oP. , t .. ' 2 V-rci, ' '.,,, cll , , . ... . . , , t.,. —4 ; , .,I ; m , ' , ' , 1 .I . . . .... ' co t1 mr-rvail °nand Clonorchiasis Gonorrhea Soft chancre Syphilis Favus Trachoma Tuberculosis Chronic alcoholism Psychopathic inferiority Insanity Epilepsy Idiocy, imbecility, feebleminded, mentally defective Total Disease or defect of less degree Disease or defect which affects ability to earn a living (2) Loathsome contagious or dangerous contagious diseases (1) Idiocy, imbecility, feebleminded, insanity, mentally defective, epilepsy, tuberculosis, chronic alcoholism Number of alien passengers examined CCri • ii 0 0 td el, 0 gLT Alien passengers certified DIAllaS r.., . . . . . ... ,—. . . . . .I I I , , to c.. ... . ..... . .: : ., m ; . .. ...., .to .. , , . .., .. ' ', .. .: .. n.., c. c.” b.pcnw ...,... . ..,. ommo.....,.,w000000..,omm.mmo o ,.., . C . .... tow, c, oc... .. ....... . ,. . ...m. . . , .... ... I . .m,. .m.m.... ,-, . 0.,. .. ...m . -.., ... mcomo. . . co ... m....... . . . . . . .....m.. .,. ,,.. . .o.m.,...,.,,.0,...m......... '" t ttCD CD n CD CD ,, ,5 '''.12a;",--,•-d44,F,api=, 5.-,- - °;oP'•-12 - p 6-42 g•7'.9 E.: ca"ac ; a t .:P ., 0.*,_-i p,..:(4 3;.',.-, E2 '4 ,-3`°,,`,-gt(3-,-,",.F,ff:n•p,;?'-P I-3.g- ' ,°< -"--,_,E,•;': °<8.•°z-,,,!4.' -1 Class A Important diseases for which certification was made 161 2 4 11 1 40 1 143 2 4 1 6 313 4 25 34 3 48 11 6 640 0 41 3 1 28 18 20 1, 254 27 108 4 2 1, 606 146 3 1 47 40 5, 157 64 5 11 11 2 171 12, 551 151 109 41 31 2 0 1 0 27 79 131 0 326 5 9 15 22 3 1 4 2 1 30 110 199 4 50 113 4 34 27 8 70 5 2 1 19 3 373 105 7,140 75 81 15 11 3 3 13 2 1 1 2 4 3 1 2 4 101 43 71 12 3 37 1 1 69 17 1 75 3 3 2 2 9 4 15 10 1 1 4 32 28 39 40 11 74 1 14 3 1 1 3 19 4 6 1 3 4 3 1 1 2 2 4 1 3 23 2 0 0 1 0 59 5 162 2 46 11 3 50 2 11 0 Formerly St. Johns River, Fla. 4 1 case leprosy, Laredo, Tex. 1 2 1 1 6 3 1 8 1 1 5 16 1 1 1 2 1 1 1 4 3 1 6 5 Formerly Biscayne Bay, Fla. 6 1 case leprosy, Philippine Islands. 4 aDIAllaSVaH DIrlallcl Gloucester, MasS 9 4, 370 Halifax, N. S 33 Havre, Mont 21 Hidalgo, Tex 30, 138 19 Honolulu, Hawaii 2 1, 265 2 Hou1ton, Me 27 International Falls, Minn_ 7 769 1 Jackman, Me 31 3 Jacksonville, Fla.5 12 Ketchikan, Alaska 0 Key West, Fla 3 8, 344 Laredo, Tea.4 219 20 28, 189 Lewiston, N. Y 0 Marcus, Wash 3 413 Miami, Fla.5 1,458 Mobile, Ala 141 101 143 Montreal, Canada 22,721 31 84 Naco, Ariz 3,619 1 New Bedford, Mass 197 1 New Orleans, La. (city) 339 New Orleans, La. (quarantine) 4, 083 24 2 Newport, Vt 3,953 81 173 New York, N. Y 271, 371 12 Niagara Falls, N 4,229 3 20 Nogales, Ariz 11, 194 7 8 Noyes, Minn 303 1 Ogdensburg, N. Y 8 65 Oroville, Wash 183 Pascagoula, Miss 0 Pensacola, Fla 10 Perth Amboy, N. J 2 Philadelphia, Pa 532 Philippine Islands 6 48 1 11,515 Portal, N. Dak 3 581 10 Port Angeles, Wash 0 3 Port Huron, Mich 54 2,782 Portland, Me 130 2 3 Oreg 11 Porto Rico (other than San Juan) 1,065 Port San Luis, Calif 5 1 Port Townsend, Wash 2,119 12,692 Presidio, Tex 4 3,144 Providence, R.I 2 1 8,387 Quebec, Canada Rio Grande, Tex 1 6 260 9 4 Rouses Point, N Y 593 Sabine, Tex 25 Fprmerly Hoquiam, Wash. 2 1 case leprosy, Honolulu. Hawaii. ? ..!. ,1 " '' ' 4 r S'I'D-5) '''' r.: ,4. . . .4. w w . .. .4 . . . ..4 w Clonorchiasis Gonorrhea Soft chancre Syphilis Favus Trachoma Tuberculosis Chronic alcoholism Psychopathic inferiority Insanity Epilepsy Idiocy, imbecility, feebl minded, mentally defective Total Disease or defect of less degree Disease or defect which affects ability to earn a living (2) Loathsome contagious or dangerous contagious diseases DIAITHS HEIVRI-1 Orffincl ,— . .., w .. . .. w . a, . w. .,-,. . . .4. . . . ow . w. .. ... w . w . .. ..4 o.— w.4. .. o.w.o..4o 0.....w.00...wm,.. w . . . . .4. c„ 0,,__. ,,,, ,...,_,,- u, . ,c, , (1) Idiocy, imbecility, feebleminded, insanity, mentally defective, epilepsy, tuberculosis, chronic alcoholism Number of alien passengers examined 2 0 i 0 0 5 `65' Class A . . .. .. . .4,4. ci.. w w.,....,. w ..4. w.. .....4,. co.. owm .o..womw .o. . ,.....ow.4,4.,..,. owwwo.. vg 54 : 5. - —0 ,PC a P 3 .3.3,-.3,wWW,72,V4'g=,`,'-i-` .8.it ri , , , F, 5.,st. cr l ,' ,F,(-2 pA „.0.0,v 00 0 0 ., ,. . • '''C<•,ICC'•-3, .5,•P it Alien passengers certified Important diseases for which certification was made tLi 29 7 614,972 731 Formerly San Fernando, Ariz. 3 1,216 1,040 140 14,014 136 119 7,915 1,208 266 23,876 6 3 212 3 1 2 1 48 86 138 36 17 1 1 195 498 2 39 147 58 364 110 West Palm Beach, Fla., established Apr. 1, 1926. orffincr Total 0 7 17,762 24,153 aDIAllaS REIVH1-1 West Palm Beach, Fla.8 Wilmington, N. C Winnipeg, Canada Yarmouth, Nova Scotia .:-'..74 : S . ..r" ....‘ ...) ...54e. - tgt . ,--. . t. ........... 1 . i ......... 1 .. - 7. - .. .. , o .- gt. ..-. , ,..,. o El ..-,c.., .. ..... rf7 a '71 onana Clonorchiasis Gonorrhea Soft chancre Syphilis Favus Trachoma Tuberculosis ' Chronic alcoholism Psychopathic inferiority Insanity Epilepsy Idiocy, imbecility, feebleminded, mentally defective Total Disease or defect of less degree Disease or defect which affects ability to earn a living (2) Loathsome contagious or dangerous contagious diseases (1) Idiocy, imbecility, feebleminded, insanity, mentally defective, epilepsy, tuberculosis, chronic alcoholism p'—‘ E 0 E2 0 i ,- a Number of alien seamen examined aDIAllaS FlIrIVaH ..... ....... W .... ....... ........... " ........ 7 .. .-b., C75 N= .. ..... ...... ... ....... ..... ........... .......... ......... i. .... ............ .... . ...,00 000000ts.700ts. t...,0000C4C, , 0 ... — bp .... . ......... .......... ....... ............. t•D 0., -..... - ,... .. , 0W0..000 ....1CAWW0000,000,U0W001P. a.' t g - V- .E.4"..? 4 Pv48 49 ..1 .'''. - v,9,p,•2? - 4 0,'-,5) 4 .1g -nm4ggs' P° q q...1),,-3-4-444.4 ii 1"9: Zcn L' i-c:y`? g ''..- 4 , ' FP .-3E4.5•51 4 l''' c. I. 74' a P w .3' • =; • . $ l ' ' 0 0 -2 ..,''i , . n nnwwwwwww 4gn.7,,tS§(402Igig-g',444,-4-8 F, FJ'''-4-4,Y57,ig .ri.9 g4,icrgi';7,42.5w5i."1. .-F.E.gilggP--a 9LT Alien seamen inspected and certified at all p6rts in the United States and Canada Alien seamen certified Important diseases for which certification was made 12 5 134 3 0 0 0 1 0 0 0 5 1 1 85 2 35 1 2 1 4 26 24 3 19 1 59 10 2 7 6 1 2 32 63 20 6 3 3 1 21 15 2 2 1 20 4 4 2 6 348 3 12 2 147 9 9 1 3 1 5 Formerly St. Johns River, Fla. 5 1 52 1 4 1 1 1 0 0 0 4 35 0 0 1 33 0 0 436 0 0 0 15 0 4 46 2 239 0 0 0 0 9 4 21 3 19 0 2 1 0 0 24 0 0 0 4 23 10 2 1 7 2 1 11 53 52 _e 2 4 14 3 14 85 135 2 1 1 5 3 2 3 2 69 1 2 2 3 73 1 3 5 14 6 7 8 4 3 8 1 2 1 1 1 1 6 1 1 1 1 Formerly Biscayne Bay, Fla. 2 4 4 1 case leprosy, New York, N. Y. aDIMIRS HIrIVHH DIrlafIcT 14,903 Galveston, Tex 180 Gloucester, Mass 0 Halifax, Nova Scotia Havre, Mont Hidalgo, Tex 2 Honolulu, Hawaii 0 Houlton, Me International Falls, Minn_ Jackman, Me 2,475 Jacksonville, Fla.2 2 Ketchikan, Alaska 4, 204 Key West, Fla 0 Laredo, Tex 0 Lewiston, N. Y 0 Marcus, Wash Miami, Fla.3 6,213 7,706 Mobile, Ala 0 Montreal, Canada 0 Naco, Ariz 301 New Bedford, Mass 3, 266 New Orleans, La.(city) New Orleans, La.(quarantine) 52,555 0 Newport, Vt 474,285 New York, N Y. 0 Niagara Falls, N Y 0 Nogales, Ariz 0 Noyes, Minn 696 Ogdensburg, N. Y 0 Oroville, Wash 115 Pascagoula, Miss 2,820 Pensacola, Fla 73 Perth Amboy, N. Y 29,621 Philadelphia, Pa Philippine Islands Portal, N. Dak 54 Port Angeles, Wash 0 Port Huron, Mich 5,981 Portland, Me 4 Portland, Greg Porto Rico (other than San 10,632 Juan)_ 273 Port San Luis, Calif 20, 735 Port Townsend, Wash 0 Presidio, Tex 4, 151 Providence, R. I 5 Quebec, Canada Rio Grande, Tex Rouses Point, N. Y 8,984 Sabine, Tex 0 St. Albins, Vt 0 St. John, New Brunswick____ 4,739 San Diego, Calif 34,972 San Francisco, Calif 1 Formerly Hoquiam, Wash. i Formerly San Fernando, Ariz. . 0 Y F ,s E IS - .f=, 4 (.,.. w 1-,1••• ' c, u o . co w , L . o . . . o . N= 5 • . . w. Clonorchiasis Gonorrhea Soft chancre Syphilis Favus Trachoma Tuberculosis HDIAIIRS FlirlVaH DIaffad . .. Chronic alcoholism Psychopathic inferiority Insanity Epilepsy Idiocy, imbecility, feebleminded, mentally defective Total . 00 oc,,..00000000. o.o.o...00.w 1. Disease or defect of less degree . c. . Disease or defect which aft ability to earn a living (2) Loathsome contagious or dangerous contagious diseases (1) Idiocy, imbecility, feebleminded, insanity, mentally defective, epilepsy, tuberculosis, chronic alcoholism Number of alien seamen examined P: 0 0 0 s,"7' E2 Class A 4, . . .. . . . . , o ..o.ow000000. oc00000=oo.. ;' mRaP" 3g4tS I1i 5d P.-P PE— zp-td?,,oed47,? oo , E ,qq.m(rv...... ggPugg.W'W8,1§41Hgt gu . ,, .0g,tglw?Igpc 2q0 td,-4-478.51 8/1 a 5 t.1 gi Yd 8' a seamen inspected and certified at all ports in the United States and Canada—Continued Important diseases for which certification was made PUBLIC HEALTH SERVICE 179 REPORTS FROM IMMIGRATION STATIONS BOSTON, MASS. Acting Asst. Surg. A. J. Nute in charge. One thousand two hundred and eight vessels from foreign ports -were boarded for medical inspection of arriving aliens. The character of alien passenger travel to Boston with respect to classification on manifests and number of certificates issued is indicated by the following table: Class 1 •2 3 Stowaways Total Number Class A Class B Class C aliens 1,107 3,622 6,618 46 11,393 0 21 4 4 29 35 286 300 2 623 16 316 584 2 918 cent Total Per certified 51 623 888 8 1,570 4.5 17.0 13.4 17.4 13.7 The medical inspection of prospective immigrants abroad by service officers has already shown certain results. It will take years to determine its true value, but a general improvement in the physical and mental types of aliens arriving from Great Britain and Ireland, particularly in regard to class A conditions, is already oticeable. Massachusetts institutions reported no public charges due to physical or mental defects among aliens medically passed at Boston during the period July 1, 1925, to June 30, 1926. One hundred and seventeen aliens were admitted to appropriate hospitals during the year. Among these were two unusual types of purpura following severe seasickness. No epidemic diseases occurred in the detention quarters, an unusual event in the history of this station. The inmates consisted mainly of Chinese aliens awaiting disposition, stowaways, and persons charged with being illegally in the United States, a total rarely exceeding 50. Arriving aliens detained, exclusive of hospital cases, have been almost negligible. EL PASO, TEX. Surg. J. G. Wilson in charge. The work of the medical examination of aliens during the past year has been of the same character as usual, immigration at this port being mostly Mexican. The laboratory service installed in the fall of 1924 is a great aid in the diagnosis of tuberculosis, syphilis, gonorrhea, favus, and ringworm. The following examinations were made: Wassermann Gonococcus Nail scrapings 107 66 48 The detention barracks at the immigration station are given general hygienic supervision and aliens detained therein receive medical attention. 180 PUBLIC HEALTH SERVICE NEW YORK, N. Y. Senior Surg. E. K. Sprague in charge. Due to the inauguration of the examination of prospective immigrants to the United States at the ports of departure in Great Britain and other European countries, the medical personnel at Ellis Island has,been in a continual state of transition. Since it seems advisable that the medical officers detailed for this duty should have had experience that can be obtained at Ellis Island only, several highly efficient officers were lost to this station. The total number of aliens arriving at the pod of New York was 271,371, an increase of 30,131 over the previous year. These aliens were classified as 53,854 first, 93,999 second, and 123,518 third class. All of the first and second class passengers were examined aboard ship in accordance with the usual practice at the port of New York. Of the third-class passengers 72,665 were examined intensively at Ellis Island. The remaining 50,953 were examined on shipboard either because they had been examined by medical officers of the Public Health Service at foreign ports of embarkation or because they held return permits issued by the Immigration Service. This change in procedure caused a decrease of 28,896 from the number intensively examined during the previous fiscal year. The number of certificates issued has decreased proportionately to the number of aliens intensively examined. Because of the reduction in the number of immigrants examined at Ellis Island, it has been possible to reduce materially the number of medical officers and clerical personnel on the line. As many medical officers as practicable have been detailed to the hospital and withdrawn temporarily, when necessary, to serve on the line or for boarding work. On May 20, 1926, the intensive examination of alien seamen was inaugurated in accordance with bureau circular No. 481. From May 20 to June 30, 60,392 alien seamen entered the port of New York, of whom 48,031 were examined intensively and 209 were sent to Ellis Island for completion of diagnosis. One hundred and twentyone of these were certified for class A—I and class A—II conditions, the remaining 88 being still under observation at the close of the fiscal year. NOYES, MINN. Acting Asst. Surg. Frank B. McIntosh in charge. The majority of aliens certified were non-English speaking, prin-. cipally Europeans of Slavonic origin, many of whom had arrived in Canada from Europe but a few days before they presented themselves for admission to the United States. The remainder of the aliens who were unable to speak English came from settlements in various parts of Canada, some of them being of Canadian birth. PHILADEL"IIIA, PA. Surg. F. A. Carmelia in charge. During the fiscal year 1926 there was but a light inbound alien passenger movement through the port of Philadelphia. 181 PUBLIC HEALTH SERVICE Seventeen special medical boards were convened for the reexamination of aliens conditionally admitted into the country following initial certification of defects on arrival at other ports. Philadelphia is being used increasingly as a port of deportation, and the immigration station and hospital at Gloucester, N. J., were occupied continuously by a large number of aliens awaiting deportation. These aliens were given a medical examination for record upon arrival in detention, and the sick were treated in the hospital. Twenty-four hundred medical examinations were made on such deportees and 1,693 medical treatments were given aliens awaiting deportation. The location of the hospital and detention building in Gloucester, N. J., necessitates almost daily inconvenient travel from the Philadelphia immigration office. PHILIPPINE ISLANDS Surg. H. F. Sthith in charge. Provision has been made for the medical inspection of aliens at all the •ports of entry in the islands, namely, Cebu, Davao, Iloilo, Job, Legaspi, Manila, and Zamboanga. Since no vessels from foreign ports arrived direct at Davao or Legaspi, no inspections were made at those ports. No facilities exist at any of the ports of the Philippine Islands for the proper medical inspection of arriving aliens, but the examinations were conducted on board arriving vessels, in the quarantine offices, or at the customhouses. The number of aliens inspected and certified were as follows: Port Inspected Certified Manila Cebu Davao Iloilo Jobo Legaspi Zamboanga 10,793 1 0 2 138 0 581 57 0 0 2 10 0 10 Total 11,515 79 The certifications were for the following causes: Tuberculosis Favus of the scalp Gonorrhea Leprosy Ringworm of the scalp Trachoma Blindness Paralysis Uncinariasis Total 1 3 1 1 40 3 13 1 16 79 The following table shows the nationalities represented by the aliens arriving during the years named: 4 182 PUBLIC HEALTH SERVICE 1920 1922 1924 14,875 81 53 750 68 79 12 24 952 79 70 33 32 563 38 10 133 13,954 73 81 519 75 67 16 31 584 43 53 42 53 375 15 15 54 12,497 63 80 644 84 70 7 24 968 47 189 71 19 403 15 7 63 12,20T 63 84 706 76 107 11 46 1,081 30, 58 41 22 401 2 3 138. 17,852 16,050 15,251 15,076. Nationality Chinese Dutch and Flemish East Indian English French German Irish Italian Japanese Portuguese Russian Scandinavian Scotch Spanish Syitan Turks Other 1925 Boards of special inquiry and boards for determining the age of arriving aliens were convened almost daily. Because of the prevalence of ringworm of the scalp and similar diseases, a considerable amount of laboratory work was necessary. Aliens arrive on practically every passenger vessel, but since thetotal number is relatively small, there are no vessels engaged in exclusively immigrant ;trade. PORT HURON, MICH. Acting Asst. Surg. George M. Kesl in charge. The overcrowded condition of the county jail at Detroit, Mich., resulted in the transfer of several large groups of detained aliens to the county jail at Port Huron. This increased number of detained aliens awaiting deportation in this city required frequent visits on the part of the medical officer to provide necessary attention in cases of illness. Forty-five alien prisoners were •treated 164 times at the county jail and 4 alien prisoners were provided with hospital treatment for a period of 26 days. At the request of the Commissioner of Immigration and the district director of the United States Immigration Service at Detroit, Mich., the medical officer in charge made a sanitary survey of the St. Clair County jail and submitted a report covering the subject_ No serious insanitary condition was discovered. PRESIDIO, TEX. Acting Asst. Surg. C. M. Hatcher in charge. Immigration through this port has practically ceased, largely due to the immigration act of 1924 and the remoteness of the port from. an American consulate. Most of the aliens examined were Mexicansfrom the neighboring town of Ojinaga and the surrounding territory. Since the official personnel of the port consisted of but three persons, the medical officer served as a member of the board of special inquiry convened by the immigration officer. PUBLIC HEALTH SERVICE 183 SAN FRANCISCO, CALIF. Surg. Dunlop Moore in charge. The activities of the service at this station may be discussed under the following headings: (1) Medical inspection of aliens, (2) hospital, (3) laboratory, (4) miscellaneous. Medical inspection of aliens.—Again a falling off in the number of alien passengers arriving at this port as compared with the preceding year is noted. This phenomenon is ascribed to enforcement of the recent restrictive legislation and to unsettled political conditions in some parts of the Far East. It is noteworthy, however, that the number of alien passengers examined during the final quarter of the fiscal year was greatly in excess of the number for any similar period since the effective date of the immigration act of 1924. While it is realized that the practice of conducting physical and mental examinations of alien steerage passengers on board ship is unsatisfactory in most respects, nevertheless, owing to factors not within the control of the medical officers, the number of steerage passengers remanded to the Angel Island immigration station for intensive medical examination shows a distinct diminution. Under present conditions at this port, not only are all cabin passengers medically inspected on board ship, but also the medical examination of certain classes of alien steerage passengers is habitually completed on shipboard, namely, those holding permits issued under section 10 of the immigration act of 1924 (so-called return permits) as well as rail and water"transits"; whereas at one time all steerage aliens, with few exceptions, were remanded to Angel 'Island for intensive medical examination. Viewed from a purely medical standpoint, the immigration station presents many important advantages as a place for conducting the careful physical and mental examinations contemplated in the immigration laws. Hospital.—Of diseases requiring hospital treatment first in point of numbers was scabies, represented by 41 admissions, with two exceptions, all Chinese. Scabies is an extremely common skin affection among our Chinese, neglected and aggravated forms of the disease being frequently encountered. As a common sequela of this condition extensive pigmented areas, puzzling to the uninitiged, are often seen. In contrast to the frequency of scabies, the rarity of pediculosis among arriving Chinese is worthy of mention. Notable, too, is the entire absence from our hospital record for the fiscal year 1926 of such common infectious maladies as measles, scarlet fever, diphtheria, and whooping cough. Thus the hospital report apparently indicates improved sanitary conditions among arriving and detained aliens. Laboratory.—The laboratory facilities though somewhat limited, the medical examination of have proved of value in connection with' aliens as well as of assistance in the diagnosis of hospital cases. A large proportion of the incoming aliens originate in the southern Chinese Province of Kwantung, whose indigenes present an intestinal fauna of perhaps unsurpassed richness and variety, so that the examination of feces has long been regarded as a most productive feature of the laboratory work. Stool examinations, though much fewer than in previous years, were made with results as follows: 184 PUBLIC HEALTH SERVICE Specimens of feces examined Negative Specimens containing ova of— Ascaris lumbrieoides Trichuris trichiura Hookl,vorm_, Clonorchis sinensis Fasciolopsis buski T. saginata 11. nana Metagonimus yokogawai Oxyuris vermicularis Schistosoma mansoni Specimens containing larvae of strongyloides stercoralis Number 953 333 441 246 118 104 7 4 1 1 1 1 5 Needles to add, polyparasitism is of extreme frequency. The above table fairly represents the order of frequency of the more common helminths among the Chinese of Kwantung Province. First comes roundworm and second whipworm ; hookworm and clonorchis are close contenders for third place, with Fasciolopsis buski and Strongyloides stercoralis following almost pani passu far behind. Miscellaneous.—Among miscellaneous duties may be noted the following: There were 1,377 out-patient treatments given to detained aliens and others suffering from minor ailments not requiring hospitalization. One hundred and fourteen aliens and others were vaccinated against smallpox. It appears that for some time the local consul general of Mexico has required a vaccination certificate as a prerequisite to the deportation of his nationals. With reference to their physical fitness to perform the duties of seamen, 138 aliens were specially examined prior to deportation, 5 of whom were found physically unfit. Thirty-eight estimates of probable age were made and certificates of findings issued. In this connection special attention has been given to 't the possible effect of intestinal parasitism in retarding physical development. Members of the hospital staff, when required, have appeared before local courts in connection with the commitment of aliens afflicted with.mental disease or drug addiction and have made reexaminations of certified aliens. Upon request of the Commissioner of Immigration medical examiExecutive order nations have been made and certificates issued under' of June 18, 1923, of applicants for positions in the local immigration service. Analysis of the medical records of this station throws valuable light upon the nosogeography of Asia, a subject which, though still shrouded in much obscurity, possesses great present interest and greater potential importance to the American health officer. The diseases of the immigrant from the more enlightened countries of Europe are very similar to those prevailing among our own people; whereas in Asia and particularly in southeastern Asia, endemic maladies which have not yet secured a foothold in any other part of the globe flourish. It has been customary to ascribe the localization of these diseases to the limited habitats of the intermediate host or hosts concerned, passage through one or more animal vectors being required for their transmission from man to man. Peculiar habits PUBLIC HEALTH SERVICE 185 of diet, climate, etc., have also been regarded as secondary etiological factors. It must be admitted that our knowledge of the pathogenicity and epidemiology of these maladies is far from complete. The records of this station also indicate that the human pathology of Asia when compared with that of the United States and Europe shows marked quantitative as well as qualitative dissimilarities. An everyday illustration of this fact is the tremendously high rate of infestation with roundworm found among southern Chinese, among whom, on the other hand, cestoda are practically unknown. A large number of such examples might be readily adduced. The great Continent of Asia, out of which have emanated in the past most of the tremendous epidemics that have vexed the human race, may still retain within her bosom capabilities for evil toward which it behooves the health officer to assume a cautious attitude. A new era confronts us, and we have every reason to believe that in the immediate future the distances that have hitherto separated the circumpacific countries will be annihilated by the progress of invention and that the distinctions now existent between the nosology of these widely separated districts will tend to become obliterated. As a power with Asiatic dependencies, it is of interest to the United States to consider the possibility of maladies hitherto regarded as distinctively American thus gaining entrance into Asia. In this connection it is worthy of note that a medical officer of the United States Public Health Service was recently able to demonstrate conclusively the presence in Japan of tularemia, a disease not previously described outside of the limits of the United States. WINNIPEG, MANITOBA, CANADA Asst. Surg. G. J. Van Beeck in charge. As in previous years, all medical inspections were made in one room which forms part of the suit occupied by the immigration authorities. While the room in itself is adequate under present circumstances, it contains very little equipment, and this fact together with several others tends to make the inspections less thorough than is desired. Approximately 60 persons must be inspected daily, and each one singly in the order in which he arrives at the station. Further, there is no nurse or other female attendant and the station has no hospital connections. Without doubt, a number of certifiable conditions are not detected. As the station is situated in a foreign country, there are no detention quarters. Laboratory facilities are made available by various institutions in the city and their character is excellent. On the whole, the class of aliens admitted through this port has been of the best. Over one-half were visitors, the majority of whom remained in the United States for a short period only. A considerable number crossed the boundary for the purpose of obtaining medical treatment, principally at the Mayo Clinic in Rochester, Minn. • Of the total number admitted, approximately- 80 per cent were Candian citizens. The remainder (20 per cent) were of European nationality. Asiatic iwnigration through this port was so small as to be negligible. It is estimated that less than 2 per cent of the number admitted were not bona fide Canadian residents or immigrants, but were foreigners seeking entrance into the United States via Canada. 14656-26--13 186 PUBLIC HEALTH SERVICE EUROPEAN PORTS Senior Surg. Taliaferro Clark in charge. The development of the immigration policy of the United States has been very gradual and somewhat hesitant. With the enactment of the quota act of May 9, 1921, as amended by the act of May 11, 1922, limiting the number of aliens of any nationality to be admitted to the United States in any fiscal year, the Congress announced a very definite policy in respect of immigration. By the immigration act of 1924, consular officers are charged with the responsibility of issuing immigration visas to aliens about to visit the United States and directed to refuse visas to persons known to be inadmissible or whom they have reason to believe is inadmissible to the United States under the immigration laws. This is probably the most progressive step yet taken by the Congress to improve the character of immigration. In the exercise of the functions conferred upon them by law, it soon became evident to consular officers that no great reliance could be placed on the statements of many local physicians in respect of the mental and physical status of applicants for visas, largely because of the disinclination of physicians of eminence to accept the responsibility, and in less degree because of the ignorance of others of the possible significance of certain physical and mental disabilities in relation to the enforcement of the immigration laws, which led to the issuance of improper medical certificates and the failure to issue certificates for conditions of serious import. Based on reports received through the Department of State, the Surgeon General of the United States Public Health Service, with a view of overcoming this defect in the new system and minimizing the hardships of arriving aliens, submitted, on February 10, 1925, a memorandum to the Department of Labor and the Department of State on the advisability of undertaking experimental medical examinations of aliens at foreign ports and stations. Following the receipt of this memorandum, at the instance of the Secretary of Labor, a cooperative plan was worked out by representatives of the Departments of Labor, State, and Treasury, after a study of the situation abroad, in accordance with which, and with the consent of the Governments of Great Britain and the Irish Free State, medical officers of the United States Public Health Service were stationed at the consulates of Cobh and Dublin, Irish Free State; Belfast, Northern Ireland; Glasgow, Scotland; and Liverpool, London, and Southampton, England; to conduct the medical examinations of applicants for immigration visas for an experimental period of three months. This work was inaugurated under the supervision of Asst. Surg. Gen. J. W. Kerr. On January 7, 1926, Senior Surg. Taliaferro Clark was directed to proceed to London, England, and establish headquarters at the American Consulate General at that place for the general supervision of medical examinations of aliens at selected ports of Great Britain and the Irish Free State aid in continental Europe. The success of the new system of medical examinations in safeguarding the interests of prospective immigrants, saving them from 187 PUBLIC HEALTH SERVICE loss of time and money in proceeding to the'United States to learn whether or not they were admissible and minimizing the annoyance and delay at ports of arrival excited wide interest, in consequence of which, through representation to the Department of State by the respective Governments, two new stations were opened on March 1, 1926, one at Antwerp, Belgium, and the other at Rotterdam, Holland. Through similar representation by other governments, plans were perfected and the necessary arrangements made by the close of the fiscal year to inaugurate medical examinations, with the beginning of the new fiscal year, July 1, 1926, at the following points: Berlin Bremen, Cologne, Hamburg, and Stuttgart, GerDenmark; Bergen and Oslo, Norway. ' many; Copenhagen, In the following statistical report of the work accomplished during this period it is borne in mind that the respective immigration quotas were practically exhausted for Belgium and Holland when the work was started. The number of applicants examined in these two countries by the end of the fiscal year was too small to have any ()Teat effect on the statistical results of the new system as a whole. TABLE 1.—Distribution according to class of applicants for immigration visas who were medically examined at each station, August 1, 1925, to June SO, 1926 Name of station Antwerp Belfast Cobh Dublin Glasgow Liverpool London Rotterdam Southampton Total Total number of applicants Number of applicants in each class Quota Nonquota Nonimmigrant Percentage of applicants in each class Quota Nonquota Nonimmigrant 266 3,217 9,721 15,092 14,742 5,927 6,375 601 3,111 175 2,966 9,435 14,818 13,717 5,292 4,970 503 2,629 91 186 244 245 921 610 1,237 92 285 0 65 42 29 104 25 168 6 197 65. 79 92. 20 97. 06 98. 19 93.05 89. 29 77. 96 83. 69 84. 51 34.21 5.78 2.51 1.62 6.25 10.29 19. 40 15.31 9.16 2.(54 1.00 0.33 59,052 54,505 3,911 636 92.30 6.62 1. OS 0 2.02 .43 .19 .70 The percentage of nonquota immigrants, under existing provisions of the immigration laws, probably will gradually decrease from. year to year, since this class comprises the wives and children of United States citizens, returning aliens previously legally admitted to the United States, students, college professors, ministers and their wives and children under 18 years of age. On the other hand, the number of nonin-imigrants medically examined will vary from year to year, depending on social, economic, and other conditions. Members of this class are referred for medical examinations by visa officers only when suspected or presenting evidences of mental or physical disabilities. • It is of interest to note, referring to Table 1, that approximately two-thirds of the total applicants were examined at three stations, namely, Cobh and Dublin, Irish Free State, and Glasgow, Scotland; and that, exclusive of Antwerp and Rotterdam, where comparison 188 PUBLIC HEALTH SERVICE is misleading owing to the small number, the highest percentages of nonquota immigrants were examined at Liverpool, London, and Southampton, and of the nonimmigrants at Belfast, London, and Southampton. The percentage of the total applicants examined who were certified for mental and physical disabilities was highest at Belfast, Cobh, Liverpool, Rotterdam, and Dublin, in the order named. TABLE 2.-Number and percentage of applicants for immigration visas who were certified for different classes of disabilities Name of station Antwerp Belfast :Cobh Dublin ,Glasgow ,Liverpool iLondon ;Rotterdam Southampton Total Total number of persons examined Number certified for Class A conditions Percentage of persons examined who were certified for Class B conditions Total, classes A and B Class A. conditions Class 13 conditions Total, classes A and B 266 3,217 .9,721 15,092 14,742 5,927 6,375 601 3,111 4 10 277 416 32 65 16 6 8 18 701 1,515 1,571 674 980 473 75 326 22 711 1,792 1,987 706 1,045 489 81 334 1.50 .31 2.85 2.76 .22 1.10 .25 1.00 .26 6.77 21.79 15.58 10.41 4.57 16.53 7.42 12.48 10.48 8.27 • 22.10 18.43 13.17 4.79 17.63 7.67 13.48 10.74 59,052 834 6,333 7,167 1.41 10.72 12.13 Variations in the percentage of certification for class A and class B defects at different stations are shown in a different way in 'Table 3. TABLE 3.-Percentage distribution of persons certified for disabilities according to class of condition Percentage of certified persons who hadName of station Antwerp Belfast Cobh Dublin Glasgow Liverpool London Rotterdam Southampton All stations Class )3 conditions Total, classes A and B Class A. conditions 100 100 100 100 100 100 100 100 100 18.18 1.41 15.46 20.94 4.53 6.22 3.27 7.41 2.40 81.82 98.59 84.54 79.06 95.47 93.78 96.73 92.59 97.60 100 11.64 88.36 The value of medical examinations at foreign ports is well set forth in the following table: 189` PUBLIC HEALTH SERVICE TABLE 4.-Number and percentage of the total persons examined who were refused visas on medical certification for different classes of conditions Percentage of persons examined who were refused visas for- Number refused visas forTotal number of persons examined Class A. conditions Name of station Antwerp Belfast Cobh Dublin Glasgow Liverpool London Rotterdam Southampton Total Class B conditions All conditions, classes A and B Class .A conditions Class B conditions All conditions; classes A and B 266 3,217 9,721 15,092 14,742 5,927 6, 375 601 3,111 4 10 277 416 32 65 16 6 8 7 242 548 424 208 560 244 40 68 11 252 825 840 240 625 260 46 76 1. 50 .31 2.85 2.76 .22 1. 10 .25 1.00 .26 2. 63 7.52 5. 64 2.81 1.41 9. 45 3. 83 6.66 2.19 4. 14 7.83 8.49 5.57 1.63 10.54 4.08 7.65 2.44 59,052 834 2,341 3, 175 1. 41 3.96 5.37 Approximately 5 out of every 100 applicants were refused immigration visas on medical certification. Excluding Antwerp and Rotterdam, where the numbers examined are too small for statistical comparison, the percentage of refusals of the total examined is fairly uniform, but is highest at the industrial center-Liverpool. In respect of the number certified in each class (see Table 5), all of the applicants, or 100 per cent, certified as having class A defects, and approximately 37 out of every 100 certified as having a disease or defect potentially affecting their earning capacity were refused visas. TABLE 5.-Number and percentage of the total persons certified for each class of disability who were refused visas on medical grounds . Number of persons certified forName of station Antwerp Belfast Cobh Dublin Glasgow Liverpool London Rotterdam Southampton Total Number of persons refused visas for- Percentage of persons certified who were refused visas for- All conAll conAll conClass A Class B ditions, Class A Class B ditions, Class A Class B ditions, condi- classes condicondi- classes condicondi- condi- classes tions tions tions tions A and B tions tions A and B A and B 4 10 277 416 32 65 16 6 8 18 701 1, 515 1, 571 674 980 473 75 326 22 711 1, 792 1,987 706 1,045 489 81 334 4 10 277 416 32 65 16 6 8 7 242 548 424 208 560 244 40 68 11 252 825 840 240 625 260 46 76 100 100 100 100 100 100 100 100 100 38.89 34.52 36. 17 26. 99 30.86 57. 14 51. 59 53.33 20.86 50.00 35.44 46. 04 42. 27 33.99 59.81 53. 17 56.79 22.75 834 6,333 7,167 834 2,341 3,175 100 36.95 44.39 Of the total number of applicants certified, 44.30 per cent were refused visas, a number never approximated by medical examinations at ports of arrival. t For example, in 1920, 333,727 aliens arrived at the port of New York. Of this number, 7,549, or 2.26 per cent, were medically certified, 0.11 per cent for class A defects and 1.89 per cent • 190 PUBLIC HEALTH SERVICE for class B defects, respectively. Of the total certified, only 4.4+ out of 100 were deported, 57.6+ out of 100 class A cases and 1.9+ out of 100 class B cases, as compared with 100 per cent refusals for class A conditions and 37 out of 100 for class B certifications at foreign ports. Pending eases.—Since the citizens of the Irish Free State did not apply for their full quota of visas during the late fall, winter, and early spring months, 10 per cent of the total quota for the year were examined each month during May and June, whereas usually the quota allotment is exhausted and the examinations are restricted to nonquota and a few nonimmigrant aliens. For this reason an unusually large number of certified cases was pending at the close of the fiscal year. It will be observed, on consulting Table 6, that of the total 630 cases pending, 492 were at Cobh and Dublin, IriEh Free State. TABLE 6.—Number and percentage of cases pending at the close of the fiscal year Number of persons Name of station Antwerp Belfast Cobh Dublin Glasgow Liverpool London Rotterdam Southampton Total Percent- Percentof the age of the Number age total total of cases certified pendingexamined tat were that were Examined Certified pending pending 266 3, 217 9,721 15,092 14, 742 5, 927 6, 375 601 3, 111 22 711 1, 792 1,987 706 1, 045 489 81 334 1 33 228 264 36 39 18 7 4 0. 38 1. 03 2. 35 1. 75 . 24 .66 .28 1. 16 . 13 4. 55 4. 64 12.72 13. 29 5. 10 3. 73 3. 68 8. 64 1. 20 59,052 7, 167 630 1. 07 8. 79 Estimated on the basis of rejections for the fiscal year, all other conditions being equal, approximately 279 pending cases will be refused visas. On this basis the 11 months' work would represent a total of 3,454 rejections instead of 3,175, or 5,850 per 100,000 examined instead of 5,370 per 100,000 examined. COMPARISON OF RESULTS OBTAINED DURING DIFFERENT EXAMINATION PERIODS AND IN THE SEVERAL POLITICAL AREAS In Table 7 may be seen the comparative results of the medical inspection of applicants for immigration visas during the experimental period, August 1—October 31, 1925; the remainder of the fiscal year, November 1, 1925—June 30, 1926; and the whole period of 11 months from the beginning of the work. In Table 8 may be seen the comparative results of medical inspection in Great Britain and the Irish Free State; in England, Scotland, and the North of Ireland; in the Irish Free State; and in Belgium and Holland. The statistics relating to the examinations made on the Continent are given simply as an indication of the trend of the work in Belgium and Holland. The relatively short period during which examinations were made (March—April) and the small number examined 191 PUBLIC HEALTH SERVICE in each country during this period militate against any accurate comparison of the results with those obtained in Great Britain and Ireland. for immigration visas TABLE 7.-Results of medical examination of applicants for two periods and for the whole 11 months Total Nov. 1, Aug. 1, 1925, to 1925, to June 30, June 30, 1926 1926 59,052 100.00 7, 167 834 6,333 12. 13 1.41 10. 72 3, 175 834 2,341 5.37 1.41 3.96 44. 29 11.63 32. 66 Total examined Percentage examined in each period Total certified Total certified, class A Total certified, class B Percentage of the total examined who were certified Percentage of the total examined who were certified, class A.. Percentage of the total examined who were certified, class B Total refused visas Total refused visas, class A Total refused visas, class B Percentage of the total examined who were refused visas A Percentage of the total examined who were refused visas, class B Percentage of the total examined who were refused visas, class visas Percentage of the total certified who were refused A class visas, refused were who certified total the Percentage of B Percentage of the total certified who were refused visas, class Aug. 1, 1925, to Oct. 31, 1925 39,617 67. 04 5, 168 632 4, 536 13. 04 1. 59 11.45 2,215 632 1,583 5.50 1. 59 3.09 42. 87 12. 24 30. 63 19,435 32. 96 1,999 202 1, 797 10. 28 1.04 9.24 960 202 758 4.42 1.04 3.88 48.02 10. 10 37. 92 of applicants for visas TABLE 8.-Comparative results of medical examinations for different geographic areas England, Scotland, and north Ireland Total number examined Percentage of the total examined in each area Total number certified Total number certified, class A Total number certified, class B Percentage of the total examined who were certified: Total Class A Class B Total number refused visas Total number refused visas, class A Total number refused visas, class B Percentage of the total examined who were refused visas: Total Class A Class B Percentage of the total certified who were refused visas: Total Class A Class B Irish Free State Total for Great Belgium Britain and and Irish Holland Free State Total 33,934 57. 46 3,285 131 3,154 24,251 41.06 3,779 693 3,086 58, 185 98. 52 7,064 824 6,240 867 1. 48 103 10 93 59,052 100.00 7, 167 834 6,333 9.68 .39 9. 29 1,453 131 1,322 • 15. 57 2. 85 12. 72 1,665 693 972 12. 14 1. 41 10. 72 3,118 824 2,294 11.88 1. 15 10. 73 57 10 47 12. 13 1.41 10. 72 3,175 834 2,341 4. 22 .38 3. 89 6.86 2. 85 4.00 5. 35 1.41 3. 75 6. 57 1. 15 5. 42 5. 37 1.41 3. 96 44. 13 11.66 32. 47 55. 34 9. 70 45. 64 44. 29 11.63 32. 66 44. 84 3.98 40. 86 44.05 18.37 . 25.68 ENTAL PERIOD ANALYSIS OF RESULTS OBTAINED DURING THE EXPERIM during Approximately one-third of the applicants were examined ing Table consult d on observe be will It period. mental experi the certified for mental VII that the percentage of the total examined, l grounds were medica on visas refused and ties, l disabili physica and 192 PUBLIC HEALTH SERVICE lowest during the experimental (organization) period, not so low during the whole period August 1, 1925, to June 30, 1926, and highest during the period November 1, 1925, to June 30, 1926. These differences are largely the result of more complete orientation and organization of the working forces and the provision of better facilities for carrying on the medical examinations as the work progressed. On the other hand, it will be observed that the percentage of the total certified who were refused visas is highest during the period of organization, less high for the whole period, and least for the period November 1, 1925—June 30, 1926. There are two reasons for this difference—the greater number of applicants with serious defects presenting themselves for examination during the period of organization, which was reduced later through (a) the educational effect of the medical examinations on potential applicants, and (b) the greater care exercised at subconsulates not to allot quota numbers to applicants to be referred to visa-control stations who were obviously suffering from serious physical or mental defects. In the second place, the decreased percentage of certified cases refused visas is in part due to the finer discrimination by visa-control officers, with increasing experience in the operation of the new system, in respect of the signaficance of certified defects in their relation to the mandates of the immigration laws. Results obtained in different racial groups.—Approximately 40 per cent more applicants were examined in England, Scotland, and the north of Ireland than in the Irish Free State. On the other hand, approximately 6 per cent more of those examined in the Irish Free State were certified for mental and physical defects and about 2 per cent more were refused visas than in the group comprising England, Scotland, and the north of Ireland. Principal defects certifled.—An important index of the value of the medical inspections is the number and character of the defects certified. The relatively large number of mental conditions certified is most noticeable, due in large measure to the greater facilities for mental examinations afforded by the new system of medical examinations at foreign ports. The advantage of increased facilities and opportunity for making • medical examinations at foreign ports is strikingly shown on comparing the results of examinations for tuberculosis made at the port of New York under the old system in 1920 and 1925, with the results of similar examinations made at foreign ports from August 1, 1925, to June 30, 1926. At New York during the fiscal years 1920 and 1925 the rates of certification for tuberculosis were 11.6 and 24.4 per 100,000, respectively, as compared with the rate of 137.3 for pulmonary tuberculosis and 172.8 for all forms per 100,000 among applicants examined at foreign ports, with 100 per cent rejections. Vaccination history and vermin infestation.—A careful record of vaccination against smallpox and of vermin infestation was made of every applicant undergoing medical examination. 193 PUBLIC HEALTH SERVICE TABLE the vaccination history and the occurrence of vermin infestation of applicants for immigration visas .—Showing Name of station Number examined Successfully vaccinated Vermin infestation Body Head Number PercentNumber PercentNumber Percentage age age Antwerp Belfast Cobh Dublin Glasgow Liverpool London Rotterdam Southampton Total. • 266 3,217 9, 721 15,092 14, 742 5,927 6, 375 • 601 3,111 115 830 3,693 8,455 6,532 715 1, 142 524 1,225 43.23 25.80 37. 99 56. 02 44. 31 12.06 17. 91 87.19 39.38 4 865 6,765 5,948 2,738 997 0 17 91 1.50 26.89 69. 59 39. 41 18. 57 16.82 0 2.83 2.93 o 41 208 1,629 231 55 0 0 8 o 1.27 2. 14 10. 79 1. 57 .93 0 0 .26 59,052 23, 231 39. 34 17,425 29. 51 2, 172 3. 68 Of the total number of applicants examined, 39.33 per cent, or 39,330 out of every 100,000, were successfully vaccinated. By successful vaccination is meant evidence of a "take" or an "immune reaction" within one year of the date of presentation for medical examination. The highest percentages of successful vaccinations were observed in Holland, in the Irish Free State, and at Glasgow, Scotland. In respect of vermin infestation, the rate was 29,420 per 100,000 applicants for head lice and 3,670 per 100,000 for body lice. The heaviest infestation was observed among the applicants examined at Cobh and Dublin, Irish Free State, but an undue infestation was observed among the applicants for visas examined at Belfast, Glasgow, and Liverpool also. THE ATTITUDE OF THE PUBLIC TOWARD THE EXAMINATIONS AND THE EDUCATIONAL EFFECT The attitude of the general public toward the medical examinations is not conspicuously manifest. The relatively few who are familiar with the character and object of the work give it unqualified approval. The attitude of the applicants for visas may be characterized as receptive. The majority of them in some localities appear to have given the matter no deep thought. Individual opinion appears to be based largely upon the result of the application for a visa. If the visa is granted, the individual reaction is good, although a number of applicants rejected because of medical defects while regretting their failure to pass have expressed themselves as grateful for the information that saved them from the greater disappointment and expense the rejection at a port of arrival would have entailed. With regard to the educational effect on individuals and communities, there appears to be no unanimity of opinion. In so far as an individual is concerned, the hygienic value of the examinations is doubtful, because the majority of the applicants were adults and their habits of personal hygiene had become fixed. However, it is an undoubted fact that as the work progressed larger and larger 14656-26---14 194 PUBLIC HEALTH SERVICE numbers of the applicants presenting themselves for medical examination gave evidences of recent correction of dental defects, disinfestation of vermin, and greater attention to personal appearance. ADDITIONAL ACTIVITIES OF THE GENERAL SUPERVISOR In addition to the exercise of general supervision of the immigration and quarantine activities of the service in Great Britain, Irish Free State, and Continental Europe, Senior Surg. Taliaferro Clark was detailed to represent the Public Health Service at the Congress of the Royal Institute of Public Health held at Bristol, England, May 19-24, 1926, and the International Sanitary Conference on the Health of Merchant Seamen, held at Oslo, Bergen, and Trondjhem, Norway, June 28—July 6, 1926. These assignments have been made the subject of special reports to the bureau. DIVISION OF SANITARY REPORTS AND STATISTICS In Charge of Asst. Surg. Gen. B. J. LLOYD Health conditions throughout the United States were generally good during the fiscal year ended June 30, 1926, although outbreaks of influenza and measles caused many deaths during the early months of the year 1926. The death rates from tuberculosis and diphtheria showed further decline for the calendar year 1925, and the infantmortality rate for that year was favorable as compared with previous years, although very slightly higher than the rate for 1924. Reports of the prevalence of communicable diseases from foreign countries were generally favorable. Most of the eastern countries which usually report the greatest number of cases of cholera, plague, and smallpox had fewer cases of these diseases than during the previous year. The malaria situation in eastern Europe appeared to be better, especially in Poland. A reduction in the number of cases of malaria was reported from Russia, although the disease still presents a serious problem in large areas of that country. A marked reduction was noted in the number of cases of typhus fever in eastern Europe and in Russia. On the other hand, the increase in the number of cases of smallpox in England and the failure of the people to use the means of control of this disease in many countries, including the United States, are discouraging features. MORBIDITY REPORTS Each year shows some improvement in the reports of the prevalence of diseases dangerous to the public health received and published by the division of sanitary reports and statistics, but these reports are not as nearly complete, as accurate, or as detailed as they should be. This statement applies to both the reports from foreign countries and from the United States. COLLABORATING AND ASSISTANT COLLABORATING EPIDEMIOLOGISTS The cooperation of State and local health officers is necessary in order to secure current information of the prevalence of diseases dangerous to the public health which is essential to the Public Health Service. In order to assist in getting reports of cases and to insure prompt transmission of reports to the Public Health Service, officers d of State, county, and municipal health departments are appointe nature as officers of the Federal Government. Appointments of this in have been made since 1913, and the plan has proved helpful securing these desired reports. 195 196 PUBLIC HEALTH SERVICE At the end of the fiscal year there were 42 collaborating epidemiologists located in the health departments of States and 4,419 assistant collaborating epidemiologists in local health departments. The work in each State is under the direction of the collaborating epidemiologist, who is in most instances the State health officer, and all appointments are made on the recommendation of the State health officer. The salaries paid the collaborating and assistant collaborating epidemiologists are nominal-41 per annum. The following table shows the States in which Federal appoint ments have been made and the number of officers in each State: Collaborating and assistant collaborating epidemiologists as of June 30, 1926 State Alabama Arizona Arkansas California Colorado Connecticut Delaware. Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Collabo- Assistant collaborating rating epidemi_ ologists epidemiologists 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Collabo- Assistant collaborating epidemi- rating epidemiologists ologists State 31 14 215 286 221 0 0 9 29 9 105 535 314 117 131 18 477 78 0 2 Montana Nebraska New Jeisey New Mexico North Carolina. North Dakota Ohio Oklahoma Oregon South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia_ Wisconsin Wyoming 1 1 1 0 1 1 1 1 1 1 1 1 0 96 0 25 112 86 165 80 103 14 84 79 322 39 10 28 48 77 229 28 83 119 Total 42 4,419 1 1 1 1 1 1 1 1 1 TELEGRAPHIC MORBIDITY REPORTS Five States were added during the fiscal year ended June 30, 1926, to the list of States making weekly telegraphic reports of the prevalence of communicable diseases to the Public Health Service. They are Idaho, Pennsylvania, Rhode Island, Tennessee, and Utah. These reports are now received from 43 States and the District of Columbia. The following is a list of the States which send these telegraphic reports: Alabama. Arizona. Arkansas. California. Colorado. Connecticut. Delaware. District of Columbia. Florida. Georgia. Idaho. Illinois. Indiana. Iowa. Kansas. Louisiana. Maine. Maryland. Massachusetts. Michigan. Minnesota. Mississippi. Missouri. Montana. Nebraska. New Jersey. New Mexico. New York. North Carolina. North Dakota. Oklahoma. Oregon. Pennsylvania. Rhode Island. South Dakota. Tennessee. Texas. Utah. Vermont. Virginia. Washington. West Virginia. Wisconsin. Wyoming. PUBLIC HEALTH SERVICE 197 In addition to the regular weekly telegrams, State health officers inform the Public Health Service immediately of the presence of unusual diseases or sudden outbreaks of the more common diseases which might spread to other States. These reports are compiled immediately upon receipt, and a mimeographed bulletin is sent to State health officers, which gives a summary of the prevalence of the principal communicable diseases throughout the United States during the preceding week. In addition, the reports are published in the weekly Public Health Reports. MONTHLY STATE REPORTS Information as to the geographic distribution of cases of communicable diseases within the respective States is given in the monthly reports received from State health officers. Owing to the limited appropriation available for printing, these reports have not been published in ftill since March, 1924, but the data are compiled and are available in the division. ANNUAL STATE MORBIDITY REPORTS The annual summary of notifiable diseases in the United States for the year 1924 was published during the fiscal year. It included statistics for all of the States except Utah. The District of Columbia, Hawaii, and Porto Rico were also included. For the principal communicable diseases the tables give the number of cases and deaths for each disease in each State by months, the number of cases and deaths per thousand population in each State for the year, and the fatality rate or the number of cases reported for each death registered. For purposes of comparison the "estimated expectancy" is given. This is the estimated number of cases which might be expected in each State during each month, the estimate being based on the experience of the preceding nine years. CITY REPORTS Weekly reports of the number of cases of the principal communicable diseases and the deaths from these diseases were received during the fiscal year from about 560 cities in the United States. The city reports are valuable, as they give the earliest current information as to the number of deaths from the different diseases reported. The cases of some diseases (influenza and pneumonia, for instance) are not well reported, and the information from the records of deaths is much more trustworthy. Two summaries of the cases of communicable diseases and deaths from these diseases for the year 1924 were issued during the fiscal year. The first included cities having 100,000 population or over, and the second included cities of from 10,000 to 100,000 population. MENTALLY DISEASED, FEEBLE-MINDED, AND EPILEPTIC During the latter part of the fiscal year blanks were sent to institutions for the care of persons suffering from mental diseases, feeblemindedness, and epilepsy for the purpose of securing comprehensive data on the number of persons suffering from these conditions who• are confined in institutions in the United States. 198 PUBLIC HEALTH SERVICE The small force available for the work and the fact that this force was obliged to keep up its regular work of collecting morbidity reports, which are constantly increasing in volume, retarded the work, but at the end of the fiscal year monthly reports were coming in from 95 institutions, located in 31 States. Whenever possible an endeavor was made to secure the necessary data for all the institutions in a State from the central State agency in charge of the institutions. This was found to be practicable in only a few States, however, as the central agencies in most States did not have the detailed data in such .form as to make the figures comparable with those from other States. State boards of control, hospital commissions, departments of public welfare, and other State agencies for the care of the unfortunate have cooperated with the Public Health Service in securing the information desired, and the superintendents of hospitals and institutions throughout the country have generally been willing to give the time and attention necessary to prepare the data needed. A rough estimate indicated that reports were being received at the close of the fiscal year from about half of the institutions under State jurisdiction in the United States, and the number was constantly increasing. The solution of many important public-health problems will probably be facilitated by definite information which can be obtained from comprehensive and trustworthy statistics from institutions of this kind. It is known that certain forms of psychosis are closely related to venereal diseases, but much light is needed on many phases of this and similar public-health problems, which can be supplied in part, at least, by properly prepared statistics, collected at regular intervals. FOREIGN REPORTS Pursuant to the provisions of the act of February 15, 1893, consular officers of the United States report to the Public Health Service the cases of communicable diseases and deaths from these diseases at ports and other places in all parts of the world. These reports are supplemented by reports of Public Health Service officers stationed abroad, by official communications and published reports from foreign governments, and by the publications of the League of Nations. The health section of the secretariat of the League of Nations has enlarged its facilities for the collection and dissemination of information regarding the prevalence of dangerous communicable diseases in all parts of the world. Through the cooperation of national and local health authorities information of outbreaks of cholera, plague, smallpox, and other diseases is now collected regularly from the principal ports in the Far East and transmitted by radio broadcasts cable, and printed publications to all parts of the world. Information of the prevalence of diseases in other regions is also collected and published in weekly, monthly, and annual bulletins by the health section. Improved means of communication and the consequent increased danger of the spread of communicable diseases have made this service invaluable to all nations. It is believed that in time the result will be an awakened interest in the collection ,of reports of diseases dangerous to the public health within national • 199 PUBLIC HEALTH SERVICE boundaries, including the United States, and that public officials and the people generally.will realize the futility of attempting to conceal the presence of these diseases and the advantage of the use of vigorous, sane measures to stamp out incipient epidemics before they are beyond control. PREVALENCE OF DISEASE Preliminary reports for the United State; indicate a low general death rate for the year 1925 (11.7 per hundred thousand population in 30 States). The infant mortality rate was also low (71.5 deaths of infants under 1 year of age per thousand births). A widespread outbreak of respiratory diseases early in the year 1926 was largely responsible for high death rates for the country as a whole during the first four months of that year. An epidemic of measles about the same time caused many deaths among children. Detailed statistics for this period are not yet available. The following table gives a comparison of the cases of the principal communicable diseases and the deaths from these diseases in 1925, with similar figures for the year 1924. CASES Disease Cerebrospinal meningitis Chicken pox Diphtheria Influenza Malaria Measles Mumps_ Pellagra Pneumonia (all forms) Poliomyelitis Scarlet fever Smallpox Tuberculosis (all forms) Tuberculosis (pulmonary) Typhoid fever Whooping cough.. Aggregate populaNum- tion (in thousands) ber of States 1 1925 1924 22 33 36 36 28 36 28 28 34 28 36 36 36 31 35 36 58,726 84, 598 92,477 92,477 86,807 92,477 77,021 80,291 91,367 74,746 92,477 92,477 92,477 88,960 89,448 92,477 59,451 85,670 93,650 93,650 87,888 93,650 77,990 81,307 92, 511 75,698 93,650 93,650 93,650 90,057 90,592 93,650 Cases per 100,000 population Cases 1924 • 1925 1924 1925 1,095 162,930 97,329 1, 100 133, 100 81, 186 1.9 192.6 105. 2 1.9 155.4 86. 7 424,146 104,324 212,385 76,575 458. 7 135.4 226.8 98. 2 4,488 160,569 39,463 4,293 165,946 • 26,741 6.0 173.6 42. 7 5. 7 177.2 28.6 26,876 147,677 36,287 128,071 30.0 159. 7 40. 1 136.8 DEATHS Deaths Deaths per 100,000 Deaths per 100 cases population Disease Cerebrospinal meningitis Chicken pox Diphtheria Influenza_ Malaria Measles Mumps Pellagra Pneumonia (all forms) Poliomyelitis Scarlet fever Smallpox Tuberculosis (all forms) Tuberculosis (pulmonary)_ Typhoid fever Whooping cough 1924 1925 470 101 7,954 16,367 2,786 6,490 57 2,006 88,843 812 2,717 813 78,379 65,203 5,352 6,912 508 83 7,241 25,844 2,421 2,098 65 3,044 88,119 1,075 2,437 595 76,605 64,666 7,430 5,460 1925 1924 0.8 .1 8.6 17. 7 3.2 7.0 1 2:5 97.2 1. 1 Z9 .9 84.8 73.3 6.0 7.5 1 In addition to the number of States given, the District of Columbia 0.9 .1 7:7 27.6 2.8 2.2 .1 3:7 95.3 1.4 2. 6 .6 81.8 71.8 8. 2 5.8 is included. 1924 1925 42.9 1 8:2 46. 2 .1 8. 9 1.5 .1 1.0 .1 18. 1 1.7 2. 1 25.0 1. 5 2.2 19. 9 4. 7 20. 5 4. 3 200 PUBLIC HEALTH SERVICE Diphtheria.—In 1925, 36 States reported 81,186 cases of diphtheria, which is 17 per cent less than the number in 1924. In these States diphtheria was responsible for 7,241 deaths during 1925 and 7,954 deaths in 1924. More than 85 per cent of the persons who die from diphtheria are children less than 10 years old. Use of diphtheria antitoxin promptly on the development of the early symptoms of the disease would have saved most of these lives, and the general use of proved methods of ascertaining whether an individual is susceptible to the disease and immunizinc, those who need protection would reduce the morbidity and morality caused by diphtheria to a small fraction of the present figures. The.mortality from this disease has been reduced more than 70 per cent in the United States during the last 25 years, but a still greater reduction is possible. Influenza and pneumonia.—Thirty-four States reported 113,762 deaths from influenza and pneumonia during 1925, which may be compared with 105,109 deaths during 1924. The death rates for the two diseases combined were 123 per hundred thousand in 1925 and 115 in 1924. These rates are higher than those for the years 1921 to 1923, but lower than the rates for the three years 1918 to 1920, which included the influenza pandemic of 1918-19. During the first four months of the calendar year 1926 influenza was widely prevalent in the United States. Definite figures are not yet available except for certain population groups, but the general death rate in these groups was higher than it has been for several years. Malaria.—Malaria is an important public-health problem in those parts of the country where it prevails. It is very difficult, however, to ,get current statistics of its prevalence, as many cases of the disease are not reported. ' Twenty-eight States reported 2,421 deaths from malaria in 1925 and 2,786 deaths in 1924. Measles.—The figures for measles fluctuate widely both for different years in the same places and for different places in the same year. Thirty-six States reported 212,000 cases of measles in 1925 and about twice that number in 1924. The deaths from this disease in these States in 1925 (2,098) were about one-third of the number in 1924. However, during the early part of the calendar year 1926 measles was unusually prevalent throughout the eastern part of the country, and later the disease spread across the country to the Pacific coast. Pellagra.—More than 3,000 deaths from pellagra were registered in 28 States in 1925. This is an increase of 50 per cent over the number in the same States in 1924. This disease is prevalent in nearly all of the Southern States. Poliomyelitis (infantile paralysis).—Outbreaks of poliomyelitis occurred during the summer and early fall of 1925 in New York, Minnesota, Wisconsin, California, and other States. Twenty-eight States reported 1,075 deaths from acute poliomyelitis during 1925. In 1924 these States reported 812 deaths from this disease. Scarlet fever.—The number of cases of scarlet fever reported in 1925 was somewhat greater than the number in 1924, but fewer deaths were registered in 1925. It is possible that the apparent increase in the number of cases was the result of more nearly complete reports of cases. PUBLIC HEALTH SERVICE 201 Smallpox.—During 1925, 36 States, having a population of 93,650,000, reported 26,700 cases of smallpox and 595 deaths. Most of the deaths from the disease occurred in a few cities where the virulent type of the disease appeared. Differences in the fatality rate of this disease are shown in the reports from the following cities: Los Angeles, Calif., 1,278 cases and 33 deaths; Oakland, Calif., 498 cases, no deaths; San Francisco, Calif., 205 cases and 15 deaths; San Diego, Calif., 439 cases and 2 deaths; Washington, D. C., 59 cases and 20 deaths; Indianapolis, Ind., 545 cases, no deaths; Minneapolis, Minn., 416 cases and 144 deaths; Omaha, Nebr., 559 cases, no deaths. Contrasts similar to these are frequent in the history of smallpox in recent years. For years cases of mild smallpox may be reported in a city with very few deaths. Then, without warning, virulent cases appear and many lives are sacrificed before belated vaccination checks the disease. This has been the experience of Los Angeles, Minneapolis, Washington, Philadelphia, Pittsburgh, and many other cities. Too frequently the vaccination is limited to contacts or persons living in certain sections, and later the disease breaks out again. Tuberculosis.—During 1925, 36 States reported 76,605 deaths from tuberculosis. The death rate per hundred thousand population from this disease in these States decreased from 84.8 in 1924 to 81.8 in 1925. This reduction is a continuation of the general trend of this disease for at least a quarter of a century. If the tuberculosis death rate of 1900 (201.9 per hundred thousand) had prevailed in these 36 States during 1925 there would have been 189,000 deaths from this disease instead of 76,605, indicating a saving of more than 112,000 lives. Typhoid fever.—Thirty-five States reported 36,000 cases of typhoid fever in 1925 and 27,000 cases in 1924. The deaths in these States from typhoid fever were: 1925, 7,430 deaths; 1924, 5,352. The increase is considerable, but the death rates from typhoid fever for recent years are all low as compared with typhoid fever rates of a decade or more ago. If the death rate in 1925 in the 35 States had been the same as the death rate in the registration area in 1900 (35.9 per hundred thousand) there would have been 32,300 deaths from this disease instead of 7,430. The increase in typhoid fever during 1925 was most marked in the rural population and small cities. The cities of 100,000 or more population showed a very slight aggregate increase over 1924. These large cities usually have better control over food, water, and milk supplies and better sewerage systems than the smaller places. Whooping cough.—This disease was not as prevalent in the United States during 1925 as it was during 1924. Thirty-six States reported 5,460 deaths from whooping cough in 1925, which gives a rate of 5.8 deaths per hundred thousand population. DISEASES IN FOREIGN COUNTRIES DURING 1925 Cholera.—During 1925 British India reported about 97,000 deaths from cholera, which is less than one-third of the number reported for 1924. Most of the cases of cholera were in Asia, and India is usually the principal focus. The Philippine Islands reported nearly a thou- 202 PUBLIC HEALTH SERVICE the disease sand cases and more than 500 deaths during 1925, and Siam. in t prevalen y was unusuall parts of Plague.—This disease was reported from localities in all number total the although 1925, during a, Australi the world, except for number the than less ably of cases and deaths was consider s, countrie n America South of number a in present was 1924. Plague tively Compara Peru. and , including Argentina, Brazil, Ecuador the few cases were reported from European countries, although . warning without port disease is likely to appear at any Smallpox.—As usual, smallpox was the most widely diffused of the quarantinable diseases. British India reported more than 40,000 been deaths from this disease during 1925. In England there has 1920. since year each cases x an increase in the number of smallpo During 1925, 5,363 cases were reported, mostly in the northern counties. Fortunately the disease in England has been mild. The d.sease was present in Canada, and more than 1,200 cases were reported during 1925. In Mexico 8,735 deaths from smallpox were registered. The disease in Mexico is of the virulent type. Relapsing fever.—Like typhus fever, relapsing fever has been decreasing in eastern Europe for several years. Comparatively few cases were reported from the northern coast of Africa but in other parts of that continent there have been severe epidemics of the disease. Unfortunately, reports of the numbers of cases and deaths are not obtainable from some of the countries in Africa, where the disease has been prevalent. It has not been reported from the Western Hemisphere. Typhus fever.—Since 1920 there has been a steady and rapid decline in the number of cases of typhus fever in eastern Europe. Poland reported 168,000 cases in 1920 and 4,200 cases in 1925. In European Russia, including Ukraine, more than 3,500,000 cases were reported in 1920 and 61,500 in 1925. In South America the disease is prevalent in Chile and Peru. It is endemic in Mexico. Yellow fever.—This disease was reported from Senegal, Liberia, Ivory Coast, Gold Coast, and Nigeria, all in western Africa, during the calendar year 1925. It was not reported in the Western Hemisphere during that year, but in March, 1926, outbreaks were reported in some places in Brazil. For several years this disease has not been seen in many countries where only a few decades ago it was expected every year and where it made life uncertain for all persons who were not immune. Malaria.—Malaria is a serious problem in some parts of Russia and in eastern Europe. In Poland the number of reported cases dropped from 53,000 in 1921 to 1,775 in 1925. In Russia, in 1925, 5,125,000 cases were reported, which is 859,000 less than the number reported in 1924. Although malaria is prevalent in many countries, reports of its prevalence are incomplete and it is difficult to secure definite reports from many localities where it is known to prevail. Trachonia.—In localities where it is prevalent this disease causes much suffering and frequently results in blindness. In many countries the disease appears to be increasing, but part of the apparent increase may be due to the discovery of old cases in the course of efforts to control the disease. European Russia reported nearly 670,000 cases in 1925 and 436,000 cases in 1924. PUBLIC HEALTH SERVICE 203 Influenza.—In most European countries for which figures .are available the incidence of influenza was less in 1925 than in 1924, but Russia reported 2,606,000 cases in 1925, as against 1,854,000 cases in 1924. Anthrax.—This disease is of interest because of the danger of infection from imported hides, wool, hair, bristles, and other commodities. The disease prevails, however, among both animals and human beings in parts of the world where it is impossible to secure accurate reports of its prevalence. The available reports indicated little difference between 1924 and 1925 in the number of cases. 'SANITARY LEGISLATION AND DECISIONS State and Federal laws and regulations.—During the fiscal year the work of collecting and compiling State and Federal public-health laws and regulations was continued. Two completed volumes of such laws and regulations were received from the Printing Office during this period. One (Supplement 49) was the compilation for the year 1923, and the other (Supplement 51) was the 1924 compilation. With the exception of a few States, the compilation for the year 1925 was ready for the printer at the close of the fiscal year. The publication of annual compilations of State laws and regulations was started in 1911. Smallpox vaccination laws, regulations, and court decisions.—During the year work was commenced on a compilation of the various State laws and regulations pertaining to smallpox vaccination. Abstracts of court decisions on the subject of vaccination will also be included in the volume. When completed the compilation will show the existing provisions of law governing vaccination. Municipal ordinances and regulations.—Copies of public-health ordinances and board of health regulations adopted during the year 1925 were secured from cities in the United States having a population of more than 10,000 in 1920 for use in a compilation of municipal sanitary legislation covering the three-year period 1923-1925. This volume when issued will be the latest in a series of compilations of municipal ordinances and regulations pertaining to public health dating from 1910. Court decisions.—The abstracting and publication in the Public Health Reports of current decisions of State and Federal courts of last resort on matters pertaining to public health and sanitation was continued throughout the year. In addition there was issued a digest (Supplement 56) of all court decisions relating to public health which had been abstracted and published currently in the Public Health Reports during the years 1919 to 1925, inclusive. Comptroller General's decisions.—The abstracting of current decisions of the Comptroller General of the United States on matters relating to the Public Health Service was continued, this work being done with a view to the possible future publication of these abstracts for the benefit and use of the personnel of the Public Health Service. Requests for information.—Many inquiries were received during the year for information concerning legislation and court decisions on particular subjects of public-health interest. These requests were complied with to the fullest extent possible with the limited personnel. 204 PUBLIC HEALTH SERVICE PUBLICATIONS ISSUED BY THE DIVISION The Public Health Reports (vol. 40, pt. 2, and vol. 41, pt. 1) was issued each week during the fiscal year. It contained current information regarding the prevalence of communicable diseases in the United States and of the major quarantinable diseases in foreign countries, together with notes on administrative and preventive measures. In addition, the Public Health Reports contained articles presenting the results of investigative and research Work by investigators of the Public Health Service in the various fields of sanitary and related sciences, abstracts of court decisions relating to public health, public-health engineering abstracts, and other articles dealing with subjects of especial interest to public-health authorities, sanitarians, and public-health workers generally. Approximately onehalf of the material consisted of statistical data relating to currentdisease prevalence, printed in tabular form, and the other half of text articles. The Public Health Reports during the fiscal year contained 2,835 pages, exclusive of title pages, tables of contents, and indexes, as compared with 3,094 pages in the preceding year, 3,245 in 1924, and 3,139 in 1923. Sixty-seven of the text articles (1,010 pages) were issued as reprints, affording a more economical distribution. Eight supplements to Public Health Reports were issued during the year—Supplements 49 and 51 (772 pages) being compilations of State laws and regulations relating to the public health, adopted during 1923 and 1924, respectively; Supplement 56 (66 pages), a digest of court decisions on public-health subjects; and Supplements 52, 53, 54, 55, and 57 (186 pages) being committee and conference reports and special articles relating to some field of research. Revised .editions of 20 previously issued reprints or supplements were published during the year. SECTION OF PUBLIC HEALTH EDUCATION During the fiscal year ended June 30, 1926, 83 new publications were handled, as compared-with 123 during the preceding year. The reduction in the number of new publications during the year was due to economies necessitated by a reduced printing fund. The total number of copies of these publications and of reprints of previous documents distributed aggregated 352,890 as compared with 379,957 during the preceding fiscal year. The smaller distribution was due principally to the reduction in the size of the editions. The 352,890 publications sent in response to 28,585 public requests do not include those printed and distributed by the division of venereal diseases. There were 62 requests for the loan of stereopticon slides during the year. A total of 5,320 slides were loaned to universities, officials of the Public Health Service, sanitarians, and others, in response to these requests. The work of the stereopticon library has been greatly handicapped during the past few years owing to the shortage of slides and to the lack of funds for making new slides and replacing those which have been broken in transit. Literature and lantern slides were furnished by this section for exhibition at the Sesquicentennial Exposition which opened in Philadelphia June 1, 1926. PUBLIC HEALTH SERVICE 205 Many requests have been received for the loan of exhibit material, posters, mats, and motion pictures, but, because of the lack of funds; compliance with most of these requests has been impossible. The mailing list for weekly Public Health Reports was thoroughly revised during the year, resulting in a reduction of 565 names. HEALTH INFORMATION BY RADIO The dissemination of health information by radio and through popular articles in newspapers and magazines was continued as heretofore, articles being published in 18 languages including English. This service showed a marked increase over that of the last fiscal year. LIST OF PUBLICATIONS The following is a list of publications issued during the fiscal year: REPRINTS FROM THE PUBLIC HEALTH REPORTS During 1003. Public Health Service Publications. A List of Publications Issued the Period April, 1924, to March, 1925. April 10, 1925. 7 pages. 15, 1011. Cooperative County Health Work. By Thomas Parran, Jr. May 1925. 10 pages. 1012. Whole-Time County Health Officers, 1925. May 15, 1925. 5 pages. 1013. Status of Vaccination in American Colleges. By Robert T. Legge. May 22, 1925. 5 pages. By 1014. The Supplying of Drinking Water to Vessels in the United States. Joel I. Connolly and A. E. Gorman. May 22, 1925. 14 pages. 1015. The Effective Agent in the Prevention or Alleviation of the Chittenden Underhill Pellagra-Like Syndrome in Dogs. By Frank P. Underhill and Lafayette B. Mendel. May 29, 1925. 4 pages. 1016. Biological Products. Establishments Licensed for the Propagation and Sale of Viruses, Serums, Toxins, and Analogous Products. May 29, 1925. 4 pages. 1017. Studies on Oxidation-Reduction. VIII. Methylene Blue. By W. Mansfield Clark, Barnett Cohen, and H. D. Gibbs. June 5, 1925. 70 pages. 1018. A Method for the Examination of Neoarsphenamine and Sulfarsphenamine. By Elias Elvove. June 12, 1925. 15 pages. 1019. Canyon Automobile Camp, Yellowstone National Park. By Isador W. Mendelsohn. June 12, 1925. 12 pages. L. 1020. An Outbreak of Typhoid Fever Caused by Milk-Borne Infection. By L. Lumsden. June 19, 1925. 15 pages. 1021. Tetanus in the United States Following the Use of Bunion Pads as a Vaccination Dressing. By Charles Armstrong. June 26, 1925. 6 pages. 1022. Studies of Impounded Waters in Relation to Malaria. By E. H. Gage. June 26, 1925. 19 pages. 1023. Some Properties of Iron Compounds and Their Relation to Water Clarification. By Lewis B. Miller. July 3, 1925. 8 pages. 1024. The Chronological Development of Federal Health Legislation and Public Health and Medical Activities. By James A. Tobey. July 3, 1925. 5 pages. 1025. City Health Officers, 1925. Directory of Those in Cities of 10,000 or More Population. July 3, 1925. 12 pages. 1026. The Bio-Assay of Thyroid. By Reid Hunt. July 10, 1925. 6 pages. 1027. Standardization of Pollen Extracts by the Complement-Fixation Test. By Charles Armstrong and W. T. Harrison. July 10, 1925. 6 pages. 1028. Notes on the Clarification of Colored Waters. By Lewis B. Miller. July 10, 1925. 9 pages. 1029. Drinking Water Standards. Standards Adopted by the Treasury Department June 20, 1925, for Drinking and Culinary Water Supplied by Common Carriers in Interstate Commerce. April 10, 1925. 28 pages. 1030. The Rat-Proofing of Vessels. By S. B. Grubbs and B. E. Holsendorf. July 17, 1925. 9 pages. 206 • PUBLIC HEALTH SERVICE 1031. Strabismus and Defective Color Sense Among School Children. By Selwyn D. Collins. July 17, 1925. 9 pages. 1032. A Plan to Establish in the United States a Morbidity Registration Area; That is, an Area for the More Complete Collection of Data Relating to the Diseases of Man. By B. J. Lloyd. July 24, 1925. 12 pages. 1033. Studies on the Industrial Dust Problem. III. Comparative Field Studies of the Palmer Apparatus, the Konimeter, and the Impinger Methods for Sampling Aerial Dust. By Leonard Greenburg. July 31, 1925. 13 pages. 1034. The Trend of Pneumonia in Massachusetts. By Eugene R. Kelley and Angeline D. Hamblen. August 7, 1925. 14 pages. 1035. The Legal Authority and Limitations Governing Federal Public Health Activities. By J. W. Kerr. August 14, 1925. 10 pages. 1036. The Administration of Mercurial Preparations in Leprosy. Preliminary Report I-Mercurochrome Soluble 220. By Oswald E. Denney, Ralph Hopkins, Jerald G. Wooley, and Boyd G. Barentine. August 28, 1925. 14 pages. 1037. Destruction of Cockroaches and Devitalization of Their Eggs by Cyanogen-Chloride Mixture. By C. E. Rice. 3 pages. 1038. The Notifiable Diseases. Prevalence During 1924 in Cities of Over 100,000 Population. September 4, 1925. 32 pages. 1039. A Comparative Study of Rat-Flea Data for Several Seaports of the United States. By Carroll Fox and E. C. Sullivan. September 11, 1925. 26 pages. 1040. A Disease in Wild Rats with Gross Pathology Resembling Plague. By N. E. Wayson. September 18, 1925. 5 pages. 1041. A Note on the Method Used to Prevent the Importation of Smallpox into the Philippine Islands. By H. F. Smith and R. W. Hart. September 18, 1925. 4 pages. 1042. Stream Pollution by Wastes from By-Product Coke Ovens. A Review, with Special Reference to Methods of Disposal. By R. D. Leitch. September 25, 1925. 6 pages. 104$. State and Insular Health Authorities, 1925. Directory, with Data as to Appropriations and Publications. September 25, 1925. 21 pages. 1044. The Accuracy of Certified Causes of Death. Its Relation to Mortality Statistics and the International List. (Committee Report.) October 2, 1925. 43 pages. 1045. Relative Values of Methods of Enumerating Bacteria in Air. By W. J. McConnell and B. G. H. Thomas. October 9, 1925. 11 pages. 1046. Studies of Impounded Waters in Relation to Malaria. The Trend of Malaria in Horse Creek Valley, Aiken County, S. C. By E. H. Gage. October 16, 1925. 9 pages. 1047. Cooperative Rural Health Work of the Public Health Service in the Fiscal Year 1925. By L. L. Lumsden. October 23, 1925. 35 pages. 1048. The Notifiable Diseases. Prevalence During 1924 in Cities of 10,000 to 100,000 Population. October 30, 1925. 107 pages. 1049. A Demonstration at Tarboro, N. C., of a System for Sanitary Control of Milk Supplies of Towns and Small Cities, with special reference to operation of a municipal Pasteurization plant By K. E. Miller. November 6, 1925. 12 pages. 1050. Public Health Nursing. By J. G. Townsend.. November 6, 1925. 8 pages. 5 cents. 1051. Reinoculation as a Criterion of Cure of Experimental Syphilis, with Reference to Arsphenamine, Neoarsphenamine, and Sulpharsphenamine. By Carl Voegtlin and Helen A. Dyer. November 13, 1925. 9 pages. 1052. Water Hyacinth and the Breeding of Anopheles. By M. A. Barber and T. B. Hayne. November 20, 1925. 6 pages. 1053. Heredity and Culture as Factors in Body Build. By C. B. Davenport and Louise A. Nelson. November 27, 1925. 5 pages. 1054. Results of Schick Tests in California. By Frank L. Kelly, Ida May Stevens, and Margaret Beattie. December 4, 1925. 14 pages. 1055. Public Health Service Publications. A list of publications issued during the period April-October, 1925. December 4, 1925. 4 pages. 1056. The Notifiable Diseases. Prevalence in States, 1924. December 18, 1925. 92 pages. 1057. The Tenth Revision of the United States Pharmacopoeia. By George B. Roth. December 25, 1925. 10 pages. • PUBLIC HEALTH SERVICE 207 Trend for the 1058. Cancer Mortality in the Ten Original Registration States. 12 period 1900-1920. By J. W. Schereschewsky. January 1, 1926. pages. By Stanley 1059. Smallpox Vaccination as Carried out at Lehigh University. Thomas. January 8, 1926. 8 pages. and duration of disa1060. Sickness Among Industrial Employees. Incidence bilities from important causes lasting longer than one week among ce 133,000. persons in industry in 1924, and a summary of the experien for 1920-1924. January 22, 1926. 19 pages. especial ref1061. Some Nutrition Experiments with Brewers' Yeast, with in experierence to its value in supplementing certain deficiencies y 5, mental rations. By Maurice I. Smith and E. G. Hendrick. Februar 1926. 7 pages. Preven1062. A Further Study of Butter, Fresh Beef, and Yeast as Pellagra of Pellagra tives, with Consideration of the Relation of Factor P-P er, (and Black Tongue of Dogs) to Vitamin B. By Joseph Goldberg G. A. Wheeler, and R. D. Lillie. February 19, 1926. 22 pages. Public United States 1063. Stream Pollution. I. A review of the Work of the H. Frost. Health Service in Investigations of Stream Pollution. By W. Waters. January 15, 1926. II. The Rate of Deoxygenation of Polluted AtmosBy Emery J. Theriault. February 5, 1926. III. The Rate of pheric Reaeration of Sewage-Polluted Streams. By H. W. Streeter. and February 12, 1926. IV. Quantitative Studies of Bacterial Pollution Natural Purification in the Ohio and Illinois Rivers. By J. K. Hoskins. February 19, 1926. 51 pages. By H. L. 1064. Four Cases of Tularaemia (Three Fatal) with Conjunctivitis. 4 pages. 1926. 26, y Februar Francis. Edward and Lake, C. G. Freese, . February 20, 1065. A Community Health Program. By Hugh S. Cumming pages. 10 1926. March 5, 1920. 1066. Division of Venereal Diseases, July 1-December 31, 1925. 2 pages. hip between tiro 1067. Rocky Mountain Spotted Fever. A study of the relations the infectiyeand smears tick in ms organisi a-like rickettsi of presence 12, ness of the same ticks. By R. R. Parker and R. R. Spencer. March pages. 9 1926. SUPPLEMENTS TO THE PUBLIC HEALTH REPORTS 1923. Com49. State Public Health Laws and Regulations Adopted During pages. piled by Jason Waterman and William Fowler. 1925. 485 1924. Compiled 51. Public Health Laws and Regulations Adopted During 287 by Jason Waterman, LL. B., and William Fowler, LL. B. 1925. pages. of some of the 52. The Standardization of Digitalis. A comparative studyof an improved methods of assaying digitalis, with a description and modification of the one-hour frog method. By Maurice I. Smith Wm. T. McClosky. 1925. 23 pages. Shellfish Industry in 53. Report of Committee on Sanitary Control of the the United States. November 6, 1925. 17 pages. Spectrophoto54. Studies on Oxidation-Reduction. IX. A Potentiometric and the metric Study of Meriquinones of the P-Phenylene Diamine and D. Benzidine Series. By W. Mansfield Clark, Barnett Cohen, and H. Gibbs. December, 1925. 61 pages. ls in Cell Sus55. Studies on Oxidation-Reduction. X. Reduction Potentia Clark. pensions. By R. K. Carman, Barnett Cohen, and W. Mansfield January, 1926. 34 pages. Decisions Ab56. Court Decisions Relating to Public Health. Digest of stracted and Published Currently in Public Health Reports During Period 1919-1925. Prepared by William Fowler. 1926. 66 pages. PUBLIC-HEALTH BULLETINS People. By 148. Mental Hygiene with Special Reference to the Migration of Walter L. Treadway. February, 1925. 190 pages. 25 cents. to Mos153. A Study of the Top Minnow Gambusia Holbrooki in its Relationpages. quito Control. By Samuel F. Hildebrand. May, 1925. 136 Engineers, 154. Transactions of the Fifth Annual Conference of State Sanitary 160 held at Cincinnati, Ohio, May 26, 27, and 28, 1924. April, 1925. pages. 208 PUBLIC HEALTH SERVICE 155. The Course of Cancer Mortality in the Ten Original Registration States for the 21-Year Period, 1900-1920. By J. W. Schereschewsky. June, 1925. 118 pages. 156. Transactions of the Fifth Conference of Malaria Field Workers. Held at New Orleans, Louisiana, November 25 and 26, 1924. August, 1925. 142 pages. 157. Health Hazards of Brass Foundries. I. Field Investigations of the Health Hazards of the Brass-Foundry Industry. II. Laboratory Studies Relating to the Pathology of Brass Foundrymen's Ague. By John Arthur Turner and L. R. Thompson. August, 1925. 75 pages. 158. Proceedings of a Conference to Determine Whether or Not There is a Public Health Question in the Manufacture, Distribution, or Use of Tetraethyl Lead Gasoline, Held at Washington, D. C., May 20, 1925. August, 1925. 116 pages. 159. Studies in Natural Illumination in School Rooms. Parts I and II. A Report on the Observations of Daylight Illumination of Selected Classrooms of Different Orientation During the Period of an Entire School Year. By Taliaferro Clark and Arthur F. Beal. January, 1926. 57 pages. 160. Transactions of the Sixth Annual Conference of State Sanitary Engineers. Held at Louisville, Kentucky, April 25 and 27, 1925. January, 1926. 142 pages. 161. Transactions of the Twenty-Third Annual Conference of State and Territorial Health Officers with the United States Public Health Service, held at Washington, D. C., June 1 and 2, 1925. HYGIENIC LABORATORY BULLETINS 142. Key-Catalogue of the Worms Reported for Man. By C. W. Stiles and Albert Hassall. January, 1926. 196 pages. 143. Studies on Brucella (Alkaligenes) Melitensis. By Alice C. Evans. August, 1925. 67 pages. 144. Digest of Comments on the Pharmacopceia of the United States of America and on the National Formulary for the Calendar Year Ended December 31, 1922. By A. G. DuMez. April, 1926. 272 pages. MISCELLANEOUS PUBLICATIONS 11. Official List of Commissioned and Other Officers of the United States Public Health Service; also List of U. S. Marine Hospitals, Quarantine, Immigration, Relief Stations, and Quarantine Vessels. July 1, 1925 71 pages. DIVISION OF MARINE HOSPITALS AND RELIEF In Charge of Asst. Surg. Gen. F. C. SMITH The demands for medical relief have been undiminished, and the resources of the service have been severely taxed to supply basic requirements. The increase in Coast Guard personnel and the natural growth of the businesses in which beneficiaries are employed serve automatically to increase the responsibilities of the service from year to year. ECONOMIES Without pride of achievement, a further reduction in the operating costs of the marine hospitals is again reported. The average per diem cost of all hospitals has been gradually reduced from $4.08 in 1923, $3.89 in 1924, and $3.80 in 1925 to $3.71, a point below the minimum compatible with full efficiency and much lower than the operating costs in hospitals of the Army, Navy, or Veterans' Bureau. The appropriations having been reduced, the amount expended on relief work was S86,294 less than for the preceding year. It was therefore necessary to limit the amount of hospital relief, and 20,743 less patient days were furnished. Otherwise, a lowered standard of hospital care would have brought forth criticism from both beneficiaries and shipowners, who naturally expect the most prompt return to maritime duties that modern hospital facilities will permit. The unit cost of treatment has indeed been reduced, but it is not possible to state that the necessary Federal work has been done and done well, because the lack of funds has limited the amount of relief that it was possible to furnish and called for some sacrifice in efficiency. . The replies from medical officers in charge of various stations, some of which are quoted below, that were received in response to bureau admonitions regarding further economies, reveal the state of mind at representative relief stations. They indicate that the limit of economy has been reached and that further restriction can but result in vexation and general dissatisfaction. Stapleton, February 17, 1926.—Expenditures have been reduced as far as is consistent with satisfactory service, and perhaps they have gone even beyond that. Hudson Street, New York City, February 20, 1926.—It is not seen how this station can diminish its professional personnel unless it ceases some of the work which it is now doing. Savannah, February 19, 1926.—No further reductions can be made consistent with efficient administration. Cleveland, February 17, 1926.—No avenue of further curtailment is evident. Detroit, February 19, 1926.—No further decrease of expenditures can be anticipated without a further lowering of hospitalization standards. Mobile, February 18, 1926.—Any material reduction in the ratio of current expenses could but result in a degree of efficiency below that of the usual hospital standards. 209 210 PUBLIC HEALTH SERVICE Buffalo, January 7, 1926.—With the existing status of the appropriations it may not be good judgment for us to attempt to improve our service, as better service would undoubtedly mean more patients and more work, which in turn would mean greater expenses. March, 22, 1926.—We do not see at this time where further• reduction in expenses can be made without changing materially the quality and efficiency of the service rendered. Baltimore, February 25, 1926.—No further reductions are consistent with efficient administration. Fort Stanton, February 24, 1926.—This hospital is being conducted with a minimum of expenditure, and it is not possible to reduce it without lowering the standards of hospital service rendered. Boston, January 20, 1926.—It is hard for us to understand the continued reduction in the funds because of the fact that we have economized in every way we know possible other than taking measures that would cripple hospital administration. UNITED STATES COAST GUARD The Public Health Service is designated by law as the medical corps for the Coast Guard. Hospital and out-patient treatment are furnished, and medical boards serve to maintain a proper physical standard among recruits, both of officers and enlisted personnel, and regulate retirements, promotions, and separations. Medical and surgical supplies are furnished to ships and shore stations, and medical and dental officers are detailed from this service to the Coast Guard for assignment to cruising cutters or elsewhere as the commandant may find necessary. Surg. J. M. Gillespie was continued at Coast Guard headquarters as medical aid to the commandant to supervise the medical relief and act as liaison officer with the Public Health Service. He reports that the personnel of the Coast Guard throughout the fiscal year ended July 1, 1926, averaged 9,839, an increase over last year of 2,762, or about 39 per cent. He believes that a further increase for the ensuing year of 1,135 will occur, and estimates that this additional personnel will require approximately 12,000 additional hospital days, 14,000 out-patient treatments, and 2,000 physical examinations. Numerical strength of Coast Guard and medical services given Number of Coast Guard personnel Year 4,684 4,896 7,077 9,839 1923 1924 1925 1926 Hospital days Out-patient Physical extreatments aminations 32,530 45,857 90,494 125,226 41,681 36,504 60,336 71,799 4,207 7,008 13,394 19,061 Average amount of medical service per person Year 1923 1924 1925 1926 Hospital days 8.9 7.6 8.5 7.7 Out-patient Physical extreatments aminations 6.7 9.4 12.8 12.7 0.9 1.5 1.9 1.9 biz 1 TOTAL RELIEF AND PHYSICAL EXAMINATIONS FURBISHED FROM 1915 TO 1926 TO "OLD LINE" PUBLIC UEALTH SERVICE BENEFICIARIES. (Exclusive of Services rendered to Veterans' Bureau Patients). 1,500,000 1,500,000 1 222 473 1,200,000 1,100,000 Hospital Relief 1,000,000 900,000 800,000 700,000 600,000 569,358 500,000 aDIAllaS HrIVHFI DIrlUfld 1,400,000 400,000 300,000 Out-Patient Treatments. 200,000 91,168 Physical Examinations. 100,000 0 1915 1916 1917 1918 1919 1920 1921 FISCAL YEAR. 1922 1922 1924 1925 1926 t\:‘, FIG. 2.-AVERAGE PER DIEM COST OF IN-PATIENT RELIEF, U. S. MARINE HOSPITALS, FISCAL YEAR 1926 COST PER PATIENT DAY SALARIES NO. LOCATION Baltimore. Md. BoaloiL_LasS Buffalo. N. Y. Chicago. 111. Cleveland, Ohio Detroit. Mich. 7 I__ F.vansville ind. Egyjlest. Fla. 10 11 Louisville. KY. 11020530.emphle. Tenn. 12 Mobile, Ala. 13 New Orleans La. 14 _u___ pittsbLirga„_ya. Portland, Me. 16 Port Townse64_.2Nash. 17 It. Loula.._Mp. 18 Sanarancieco Calif. _19 Savannah Ga. 20 Stapleton N. Y. 21 Vineyard Haven. Mese. 22 Cilia Island. N. Y. 43 Norfklk. Va. 82 2 , 5 General RELIEF DAYS 54,884 48.949 22.564 43 719 27.570 25.688 14.338 9,240 16.846 14.201 28.953 129.786 18.7t2 16,397 33.371 21,226 104.631 41.299 97 503 8,540 116,043 61.302 Per diem cost for General Hospitals Tuberculosis Total Hospital Relief Days 956,702 ,:rt Stanton, N. M. 7 9 -1-F 82,669 TOTAL FOOD SALARIES t5.48 12.14 2.05 2.20 2.50 2.84 2.01 2,5 2.29 2.84 2.58 2.19 1.63 2.76 1.95 1.87 2.47 1.99 1.99 2.38 1.88 1.91 2.42 1 .67 .65 .51 .68 .65 .69 .57 .72 .66 .73 .61 .53 .67 .66 .65 .66 .68 .62 .55 .77 .66 .68 1 .67 .93 1.35 .. .99 1.09 69 1.58 1.07 3.74 2.13 .63 .98 .81 Cost $ Leprosarium 66 Carville, La. 94,359 3.88 2.23 All Per diem cost for all Hospitals 'Relief Days for all Hospitals 1,133,730 2.71 2 08 Total cost EZM STATION RATION PRODUCTION P4i5TW,'W zzz/1.111.4 • / ...v x7.2 .92/.• 1..31_ .97 .57 1.03 .92 .77 1.44 .78 .87 1.00 1.03 1.46 1.02 ./ • '..WZ.69 w 11111111111111111111 ME . / y <Ma • 71 wiMriffir • IMMMIliffirr Z :01 . 11111111r . . 1.13 265,088.19 .58 Cost $ OTHER • Cost $3,572,914 62 1.28 I I FOOD OTHER 2.55 4.06 4.49 4.48 4,09 3.53 4.59 4.56 4.64 3.77 2.73 4.46 3.63 3.29 4.47 3.45 3.48 3.93 3.68 4.03 4.12 3.22 IMO ' NM 1.07 A 366,187.30 .64 .99 ..=. • ,.7.-•'. $4,205,190.01 Norrn-This study is based on items of operating expenses of U. S. Marine Hospitals, after deducting miscellaneous income received from sales of rations and meals, grease and garbage, sales of occupational therapy articles, and sales of unserviceable property, which money is deposited as miscellaneous receipts, Treasury Department. The receipts for care of pay patients, aggregating $495,990.92, is not deducted from operating expenses in calculating the per diem cost. Per diem cost for salary does not include commutation for quarters, subsistence, and laundry, which are included in "other expenses." The cost of food is that of the unprepared ration for patients only. "Other" includes all other expenses of operation, such as supplies, food for personnel, telephone, telegraph, burials, freight and express, water, gas, electricity, etc. Figures are not final and are subject to revision. onalm HOSPITAL UDIAllaSVaH GROUP OF HOSPITALS 213 PUBLIC HEALTH SERVICE Twenty-three medical and dental officers were detailed for exclusive duty with the Coast Guard for duty aboard cruising cutters and at important shore stations, and 103 contract physicians furnished relief for the personnel at section bases and other units remote from the regular relief stations. In addition to the medical and surgical supplies furnished as usual by the Public Health Service to cruising cutters and bases, five destroyers were medically equipped during the year, and the following first-aid and emergency supplies furnished to patrol boats and other Coast Guard units: First-aid kits Patrol-boat kits Station medical kits 432 197 252 The expenditure for emergency relief incurred by the Coast Guard q_t civilian hospitals having no contracts with the Public Health Service, both in the United States and in foreign countries, is increasing. UNITED STATES EMPLOYEES' COMPENSATION COMMISSION Civil employees of the United States injured in line of duty continue to be one of the major classes of beneficiaries of the Public Health Service, which is the principal medical agent of the commission. The number of such patients treated increased 2.98 per cent over last year, and they called for 49,382 hospital days, 129,421 outpatient treatments, and 8,997 physical examinations. Nineteen out of every 100 of all patients treated at marine hospitals and other relief stations are beneficiaries of this class. The 1925 annual report of the Employees' Compensation Commission makes in part the following comment on the medical services furnished by the Public Health Service: Government hospitals and medical officers available to beneficiaries of the commission are, to the greatest extent, those of the Public Health Service. The hospitals of the War and Navy Departments may, under certain conditions when other facilities are not available, be used for the employees of other departments, but this relief is so exceptionally used as to be practically negligible, for the reason that these facilities are usually reported unavailable or impracticable except for emergency. The present medical facilities of the Public Health Service available to the commission (September, 1925) include 25 hospitals, of which 23 are general hospitals, 1 for cases of tuberculosis, and 1 for leprosy. These hospitals are distributed along the coast and waterways; but as there are only two general hospitals west of the Mississippi River the lack of adequate Government medical facilities in this great district is a serious handicap to the commission. Owing to the fact that the hospitals of the United States Veterans' Bureau are largely filled by beneficiaries of that bureau, there has been a very serious reduction in the number of claimants of the commission examined or treated under Government facilities. In exceptional cases it has been possible to obtain permission from the Director of the Veterans' Bureau to place certain individuals in the Veterans' Bureau hospitals whenever space for them is available. This permission, however, is not equivalent to the free and unrestricted use of this group of hospitals by the commission's beneficiaries. On the other hand, the commission has found that the hospitalization of industrial accident cases in close proximity to the residual Veterans' Bureau compensation claimants has frequently had an undesirable effect upon the attitude of the commission's beneficiaries in regard to compensation. It is desired to emphasize the character of the service rendered by the United States marine hospitals. Both the hospital and dispensary services included 214 PUBLIC HEALTH SERVICE every medical facility which could be utilized with advantage in each case. Specialists have always been available whenever indicated, and a full staff of opthalmologists, orthopedic surgeons, and neuropsychiatrists, with every facility for examination and diagnosis, were included on each hospital staff. Similar work done in civilian hospitals for the Government could have been obtained only at a great cost, but civilian hospitals or private physicians would not have had sufficient experience with compensation work to render as satisfactory reports of physical findings and examinations. In a review of the current year's cases treated at the marine hospitals as compared with claimants necessarily placed under the care of civilian hospitals, it is evident that services and facilities were rendered by Public Health Service which could not be procured at any price by the Government elsewhere, and that taking into consideration the departments for physiotherapy, hydrotherapy, and vocational therapy, that had a like service been procurable anywhere else it must necessarily have been at a prohibitive cost, and few, if any, civilian hospitals or physicians have been able to render in the first instance reports necessary and essential in the proper consideration of a claim from the compensation standpoint. A conservative estimate of the value of these services would be for hospital cases $3.50 per day for bed, board, and nursing, and $3 a day for medical attention; for dispensary treatments, $2.50 each; and for examinations from $5 to $10 each. This is less than the same service would cost outside Government institutions. On this conservative estimate the value of the medical service rendered for the fiscal year of 1924-25 by the United States Public Health Service to the Employees' Compensation Commission would approximate $900,000. LIGHTHOUSE SERVICE The obligations of the Public Health Service to furnish medical relief to Lighthouse Service personnel were increased by the act of May 22, 1926. This act provides (1) for the procurement, in emergencies, by the personnel in question, of medical and hospital relief at other than relief stations of the Public Health Service, and (2) authorizes the furnishing of medical, surgical, and hospital supplies for use of officers and crews of vessels of the Lighthouse Service, which maintains 662 lighthouses, 59 lightships, and 55 lighthouse tenders, with a total personnel of 3,752 men. The estimates for funds for the fiscal year 1928 have been increased $1,400 for emergency relief and $1,200 for medical supplies for the Lighthouse Service. INSTRUCTION AND EXAMINATION OF SHIPS' OFFICERS IN FIRST AID Candidates for original licenses as master, mate, pilot, or engineer must, by a requirement in the regulations promulgated by the Steamboat Inspection Service, Department of Commerce, first pass a satisfactory examination in the principles of first aid before an officer of the Public Health Service. This regulation, which became operative July 1, 1922, was brought about by the necessity for intelligent first-aid treatment at sea on vessels having no medical officer. Many permanent injuries, and even deaths, among seamen• have resulted through the lack of proper attention to minor injuries. In order to assist these candidates and men already licensed, who frequently desire the instruction, the Public Health Service gives regular instruction courses in the principles of first aid at 43 designated marine hospitals and relief stations in ports where the local offices of steamboat inspectors are located. The courses, which are uniform, cover a series of lectures by a medical officer, extending over a period of three weeks. Candidates are instructed in the use and PUBLIC HEALTH SERVICE 215 application of commonly used remedies, the dressing of wounds, bandaging, resuscitation, the sanitation of vessels, and the transmission of requests by radio for medical advice. At the end of the instruction period the candidates are examined orally and the successful ones certified to the Steamboat Inspection Service as qualified. Those candidates who are unable to attend the lectures may study approved textbooks and apply for examination when they cons'der themselves proficient. An average of 1,702 candidates have been instructed each year since the inauguration of the work, and it will be only a matter of a few years until all licensed officers on vessels of the United States have acquired a knowledge of first aid. FOREIGN SEAMEN In accordance with a custom that has prevailed since March 3, 1875, seamen from foreign ships are admitted to any marine hospital or other relief station at the request of the consul or other responsible agent. The rates for treatment, which are fixed by the Secretary of the Treasury, were, during the last fiscal year, $3.80 per day for hospital patients and $1 per out-patient treatment. In response to requests that out-patient treatment be made available to foreign seamen, particularly for venereal disease and other maladies of a confidential nature, upon their application and without formalities, instructions were issued which enable a foreign seaman to obtain out-patient treatment at any marine hospital or other relief station at his own expense. All sums derived from the treatment of foreign seamen are deposited in miscellaneous receipts. These amounted to $85,982.11 during the past fiscal year. INTERNATIONAL CONFERENCE ON THE HEALTH OF MERCHANT SEAMEN An International Conference for the Improvement in the Health of Merchant Seamen was held at Oslo, Norway, June 28, 1926, and reported by Senior Surg. Taliaferro Clark. The conference was opened by the King of Norway in person. It was sponsored by the International Red Cross and attended by representatives of all the principal maritime nations, who discussed at length the responsibilities for the care of sick and disabled merchant seamen of various countries and ways and means for providing dispensary and hospital care, particularly for seamen having venereal infection, tuberculosis, and other communicable diseases. A standard ship's medicine chest, a handbook of medical instruction, welfare agencies in various ports, and means whereby seamen might be apprised of treatment facilities were also considered. Progress was reported by various countries in the improvement of berthing and living conditions on merchant vessels, a subject that has long engaged the interest of the Public Health Service because of its intimate relation to the health of American seamen. An article by the Surgeon General of the United States Public Health Service bearing on this general subject was published in The World's Health for June, 1926: CLINICAL WORK It has not been possible to furnish all the personnel or equipment needed in all the marine hospitals. Many requests for relief were 216 PUBLIC HEALTH SERVICE disapproved because of doubtful eligibility, especially in instances where seamen had intermissions in sea duty. Inquiries have been received as to the feasibility of making permanent the eligibility of seamen who contributed from their sea pay to the marine hospital fund prior to the discontinuance of direct collections in 1884. This is a matter for the Congress to determine. Practically all the• marine hospitals have been found by the American College of Surgeons to comply with the standards promulgated by that organization. In the large hospitals weekly staff conferences are held, at which clinical matters are discussed and medical and scientific journals reviewed. The attending specialists, now aggregating 166 in number, serving the various marine hospitals assist in maintaining proper clinical standards. There has been an increasing need for radium treatment, and, from a canvass, it was found available for service patients at all stations except Key West, Port Townsend, Vineyard Haven, and Carville at charges ranging from 5 cents per millicurie-hour in Baltimore, Md., to 20 cents per millecurie-hour in Savannah, Ga. The number of necropsies has been increased. There were 699 deaths in the marine hospitals and 166 necropsies, or 23.7 per cent. A post-mortem examination is important to the medical staff, because it shows the actual conditions causing death. It is often of great importance to the relatives of the deceased, particularly where life insurance is involved and the claims of ex-service men are pending. It is also important in instances where injuries have been sustained and claims are pending for compensation. Some of the hospitals reporting the highest percentage of necropsies are the following: Marine hospital Fort Stanton, N. Mex Carville, La Chicago, Ill Mobile, Ala Buffalo, N. Y Stapleton, N Y Savannah, Ga_.New Orleans, La Vineyard Haven, Mass Baltimore, Md St. Louis, Mo Boston, Mass Ellis Island, N Y Deaths 24 29 35 21 17 89 23 45 9 43 14 38 67 Necropsies 22 19 20 11 8 41 10 11 2 7 2 4 5 Per cent 91.6 65.5 57.1 52.3 47.0 46.0 43.4 24.4 22.2 16.2 14.2 10.5 7.4 Reference to table 5, p. 251, Causes of Death, will show the large number of deaths among service beneficiaries from violence or other Of 51 deaths so caused, 41 were due to accidental external cause. traumatism, such as falls, burns, by machines, etc. Only beneficiaries who are admitted to hospital before death are here listed. Consolidated clinical laboratory report, ftscal year 1926, United States marine hospitals and second-class stations Blood: Complement fixation— 35,441 Syphilis 121 Gonorrhea 16 Tuberculosis 3,201 Erythrocyte counts 5,545 Leucocyte counts PUBLIC HEALTH SERVICE Blood—Continued. Differential leucocyte counts Malaria Typing Blood cultures Chemical determinations— Carbon dioxide (Van Slyke or similar) Creatinine Sugar Urea nitrogen Uric acid nitrogen Total nitrogen Hemoglobin Coagulation time Miscellaneous examinations Urine: Urinalyses Renal function tests Quantitative sugar Miscellaneous urine Feces: Parasites and ova Dysentery Metabolic examination Occult blood Sputum: Tubercle bacillus -4 Pneumococcus Other organisms Stomach or duodenal contents: Routine Special Spinal fluid: Wasf-ermann Colloidal gold reaction Globulin test Cell count Bacteriological examination Other examinations Bacteriological examination: Discharges— Urethral Other T. pallidum— Dark field Smear Smears, Bacillus lepra Throat smears Other miscellaneous Cultures— Throat Other Bacteriological counts Typhoid and paratyphoid examinations: Agglutination tests Feces Urine Water analysis: Chemical Bacteriological Milk analysis: Chemical Bacteriological Animal inoculations Pathological examinations: Autopsies Tissue examinations 14656-26 15 217 5,306 2, 139 511 333 68 120 531 195 123 156 2,902 1, 159 351 59, 319 580 2, 203 726 5, 182 703 65 1,285 24,116 262 150 1, 110 148 573 254 527 568 23 9 20,403 1,204 1,294 142 772 1,332 2,682 767 2,606 46 371 420 281 12 105 77 27 858 154 2,316 218 PUBLIC HEALTH SERVICE Vaccines: Autogenous Miscellaneous examinations otherwise unclassified Total examinations 54 364 192, 308 Consolidated annsal X-ray report, fiscal year 1926, United States marine hospitals and second-class relief stations Number of patients examined Number of exposures made: Chest Bone and joint Dental Gastrointestinal and urogenital tracts Miscellaneous Total 27.300 4,570 18,831 8, 718 2, 779 2,637 37,535 DENTAL UNIT There was a marked increase over previous years in the amount of work performed by the dental officers of this service, both in marine hospitals, where 30 full-time dentists are on duty, and at the other relief stations and small marine hospitals, where 33 contract dental surgeons are employed. The full-time dental officers furnished dental relief to 30,811 beneficiaries. The total number of treatments was 110,320, among the most important of which were 9,152 prophylactic treatments, 25,195 extractions, 4,534 X rays, 13,777 alloy fillings, 5,161 silicate cement fillings, and 4,211 prosthetic appliances. Splints were prepared for 69 fractures of the jaw. The entire amount of treatment was rendered at a total cost of $140,317. It would have cost $313,113 for the same amount of work if done by civilian dentists working on a fee basis. A dental officer was assigned to duty at the marine hospital, Ellis Island, to meet the increasing needs there, and new dental equipment was installed. A bulletin is issued from the Bureau Dental Unit containing varied information for service dental officers and facilitatng the exchange of ideas on problems relating to service dentistry. Dental Surg. (R) C. T. Messner is in general supervision of all dental field work and also in charge of the dental relief station at Washington, D. C. CONTRACT PHYSICIANS To meet unusual conditions in supplying medical relief to Coast Guard shore stations (principally life-saving stations), lighthouses, and lightships, the work has been organized with headquarters at certain designated marine hospitals and relief stations in districts corresponding as far as possible with Coast Guard districts. It is necessary to maintain contracts with more than 100 physicians practicing in the neighborhood of groups of these beneficiaries, whereby they devote a portion of time to treatment which otherwise could not be supplied because of remoteness from regular service facilities. These physicians treated 4,101 service beneficiaries 10,702 times, made 1,307 physical examinations, and performed 2,292 vaccinations against smallpox and typhoid, at an aggregate cost of $31,745. The accompanying table shows the general division of this work among 219 PUBLIC HEALTH SEINICE the various headquarters. The necessary administrative functions add considerably to the clerical work of the stations. Administrative headquarters Number Number of light- Number of Coast houses of conGuard phyand light- tract stations sicians ships Marine hospital: Portland, Me Boston, Mass Stapleton, N. Y Baltimore, Md Norfolk, Va Savannah, Ga Buffalo, N. Y Cleveland, Ohio Detroit, Mich Chicago, Ill San Francisco, Calif Port Townsend, Wash Relief station: Providence, R. I Philadelphia, Pa Galveston, Tex Milwaukee, Wis Total s 16 31 31 10 48 10 5 6 12 20 8 14 33 49 8 23 26 5 4 10 19 29 3 16 12 43 lo 21 15 11 11 32 4 9 297 294 103 9 11 2 10 3 3 3 10 11 1 8 3 s COSTS OF OUT-PATIENT RELIEF The average cost of an out-patient treatment.at marine hospitars and second-class relief stations is approximately 83 cents, excluding the cost of supplies. This low cost is due to the large number of minor injuries and conditions treated at stations where little dental relief or other special forms of treatment is rendered. Of the 94 relief stations of the third class only 25, the most active, are furnished with drugs and medical supplies. The average cost of these medicines and supplies was approximately 13 cents for each 'outpatient treatment. PHYSICAL EXAMINATIONS As shown in Table 3, page 246, the total number of physical examinations for the various classes of beneficiaries was 91,553. These examinations are only those of which special written reports are made to comply with specific requests and do not include the physical examinations made in connection with the treatment of patients. The character of the various examinations made for principal classes of beneficiaries was as follows: 1. General physical examination, including special tests for vision, color vision, and hearing.—This examination, which is very complete, with the patient stripped, is given to seamen from both American and,foreign vessels, to all Coast Guard recruits, and men referred from the Army and Navy, Lighthouse Service, and Coast and Geodetic Survey. The shipping act (Public, No. 302, approved March. 5, 1915) provides that 65 per cent of all seamen on American vessels must be "able-bodied" seamen, hence the significance and importance of their physical examinations, which are designed to promote the safety of ships by insuring a proper number of physically competent seamen to meet emergencies. Of the 41,604 examinations of this 220 PUBLIC HEALTH SERVICE class, 10,241 applicants were rejected. The principal causes for rejection were defective vision, diseases of the heart, albuminuria, underweight, venereal disease, and insufficient teeth. The last-named disability is more and more frequently made a cause for rejection by shipowners critical in the selection of seamen. 2. General examinations were made with special X-ray and other laboratory tests when indicated, frequently with the assistance of attending specialists, with or without a period of observation in hospital.—This examination is made for patients of the Employees' Compensation Commission and United States Veterans' Bureau in connection with claims for compensation against the Government. It is minute and complicated and involves a large amount of clerical work in the preparation. Nine thousand three hundred eighty-two examinations of this character were made. 3. Special tests of vision and color vision.—This is an examination that all pilots masters, mates, and other ship's officers must take to license from the United States Steamboat Inspection qualify for a' Service. The tests are considered so important for the safety and proper navigation of ships that for many years all such candidates have been examined by the Public Health Service exclusively. Of 6,521 men examined during the year 220 were rejected. The most frequent cause for rejection was color blindness. 4. General physical examinations to determine fitness for employment or for retirement by the Civil Service Commission.—The provisions for retirement of Government employees, especially for physical defects (Public, No. 215, approved May 22, 1920), and for compensation for disability arising from employment (Public, No. 267, approved September 7, 1916), have made it necessary for the Government to require a physical examination designed to reveal existing defects that, although not necessarily excluding the applicant from employment, are made matters of record to protect the Government from unjust claims for compensation. The certificate formerly given perhaps after a perfunctory examination by the family doctor does not adequately fill the needs. A thorough examination also facilitates placement of employees having minor physical defects so as to minimize the hazards of employment. A large number of Government employees annually request and receive this physical examination as a precautionary measure to forestall the development of organic diseases. Those in need of treatment are referred to the family physician. 5. Special examinations to determine the presence of contagious diseases.—Food handlers on passenger-carrying vessels engaged in interstate trade are required to be free from conditions whereby they might convey infection. "Carriers" of typhoid are detected by bacteriological tests, and less obscure diseases by more direct methods. Persons employed by the Government and suspected of having tuberculosis or other communicable disease in a form endangering the health of others are also sent to the Public Health Service for examination. 6. Eligibility for pension.—The Bureau of Pensions is making an increased use of the service facilities at marine hospitals and other regularly established relief stations, thus eliminating its expense for examinations by special pension boards. The examination of this class has increased from 44 in 1925 to 821 in 1926. 221 PUBLIC HEALTH SERVICE FIG. :3 PATIENTS OF U.S. PUBLIC HEALTH SEIWICE IN MARINE HOSPITALS AND RELIEF STATIONS FISCAL YEAR. 1926 5 0 4. 1 2 7 5 Relative Amount of Medical Service Furnished on the Basis of 100 for Merchant Seamen $sa.-mzn. 100 1VIorchaill. 1. 2. U. S. Coast Guard- 14.83 3. U. Employees Com:pensation. Conlmission. 11.61 4. U. Veterans 13-uzeau. PrAients 9.1.3 5. LeTers 6.58 6. Miscellaneous Non-Nautical 7.16 T. Immigration. S.7 8. Miscella.m_eams Nautical 1.66 222 PUBLIC HEALTH SERVICE RADIO MEDICAL ADVICE TO SHIPS AT SEA Requests for medical advice by radio from ships at sea increased during the year. This service is well known in shipping channels and requests are received from both American and foreigu vessels. Messages are given the right of way and handled free of charge by governmental and commercial radio stations. Marine hospitals and relief stations at the following ports have participated in this work: New York City; Key West, Fla.; New Orleans, La.; San Francisco, Calif.; Chicago, Ill.; Cleveland„Ohio; Sault Ste Marie, Mich.; Manila, P. I.; Galveston, Tex.; and Honolulu, Hawaii. CLINICAL INFORMATION A very large number of requests for information from the clinical records of patients treated in marine hospitals and relief stations is received, the most frequent reason being in connection with suits for damages or claims for compensation. The marine hospitals treat chiefly male patients, and the diagnosis of venereal disease enters into the clinical records of approximately 22 per cent of all patients. Other clinical histories contain many records of disclosures made in confidence by patients to attending physicians. These clinical records are, therefore legally termed "privileged" documents,and although medical officers in charge of hospitals are authorized at their discretion to furnish information of a nonconfidential nature to employers, relatives, or friends of patients, and to insurance companies, welfare, and charitable organizations for the benefit of patients, written abstracts of the clinical records are not usually supplied to any person except upon the written request of the patient, . and then only upon. authority from the Surgeon General. Approximately 1,200 such requests are approved annually, and the clerical work of supplying these is considerable. A perplexing situation has arisen concerning; the disposition of requests for abstracts of the clinical histories of seamen from Government-owned vessels, particularly those belonging to the United States Shipping Board. The question has arisen as to whether the rights of the seamen are paramount to those of the Government, and whether the latter may use for its purposes the information available in its own files regardless of the patient's consent. The service has been guided in this matter entirely by the opinions rendered by •the Solicitor of the Treasury and the _Attorney Gelieral. Aliens ,detained in hospital at Ellis Island at the request of the Bureau of Immigration are not furnished with abstracts from their clinical records except upon a court order. Patients of the Employees' Compensation Commission, i. e., civil employees of the Federal Government disabled as the result of employment, are not supplied with abstracts except when authorized by the Commission or by court order. DISPOSITION OF SURPLUS PROPERTY Executive order of April 29, 1922, transferred to the United States Veterans' Bureau 47 active hospitals at that time being operated by the Public Health Service for the care of World War veterans, and, directed the division of surplus medical and hospital supplies PUBLIC HEALTH SERVICE 223 and equipment on hand of which, by agreement, the service took 20 per cent. A portion of this surplus property was excess to service needs and was disposed of to prevent deterioration. For the best interests of the Government, the property was distributed chiefly to other governmental establishments through the coordinator and only a very small portion sold at auction. The service solicited the various governmental establishments known to have need for the type of property on hand and was able to effect the transfer thereto of property having an inventory value of $456,006.27, or more than 70 per cent of its excess. It was necessary to sell at auction only $30,834.01 worth of property, consisting of drugs and chemicals not used extensively in peace times, or unfit for hospital use, at least until reprocessed. Property having an inven, tory value of $118,951.12 was sold to State and charitable institutions. The total value of surplus property disposed of to date is $605,791.40. With the exception of a few items, some of which are now in process of transfer to other governmental agencies, the service has disposed of all property surplus to its needs, as shown below: Transferred to— Agriculture, Department of Electrical and plumbing supplies, automobile spare parts, drugs and chemicals, laboratory glassware, cotton duck, tents, kitchen and mess equipment for the Forest Service, Bureau of Public Roads, Bureau of Animal Industry, Bureau of Plant Industry, Bureau of Dairying, and Bureau of Entomology. American National Red Cross Woolen helmets and wristlets originally donated by the Red Cross. Commerce, Department of Medicines,surgical instruments, beds, mattresses, blankets,and first-aid dressing packets for the Bureau of Fisheries, Mines, Standards, Lighthouse, and the Coast and Geodetic Survey. Commissioners, District of Columbia Hardware and plumbing supplies for the water and sewer departments. Government Printing Office Drugs, medical supplies,surgical instruments,and bottles for use in the dispensary maintained in the Government Printing Office. Interior, Department of Hospital supplies and equipment, hardware and mechanical equipment, drugs and chemicals, laboratory and dispensary supplies, surgical instruments and appliances, dental supplies, kitchen supplies and equipment for the Bureau of Mines, Freedmen's Hospital, Geological Survey, Howard University, Office of Indian Affairs, and National Park Service, including the hospital at Yellowstone National Park. Justice, Department of Drugs, surgical instruments and appliances, bandages, laboratory glassware and equipment, dispensary supplies, beds and mattresses, small hardware and mechanical equipment for the Federal penitentiaries at Leavenworth, Kans.; McNeil Island, Calif.; Atlanta, Ga.; and the United States marshal, Valdez, Alaska. Labor, Department of Hospital beds for the Immigration Service at El Paso, Tex. National Home for Disabled Volunteer Soldiers Drugs and chemicals,surgical instruments and appliances, kitchen supplies, laboratory, dispensary, and dental supplies for the homes at Danville, Ill., Dayton, Ohio, Hampton, Va. Hot Springs, S. Dak., Johnson City, Tenn., Milwaukee, Wis., Santa Monica, Calif., 'Togas, Me. and National Training School for Boys, Washington, D.C Surgical instruments. Navy Department Medical supplies, surgical instruments, and mess equipment. Personnel Classification Board First-aid supplies. Post Office Department Drugs, medical and surgical supplies, appliances, etc., wheel chairs, mattresses, and blankets for emergency use in the larger post offices. Public buildings and public parks of the National Capital Drugs, surgical instruments, and other dispensary supplies, small hardware, cotton duck, gas-mask fabric, and certain other textiles. Shipping Board Cotton duck. Smithsonian Institution - Small hardware, plumbing and electrical supplies, and kitchen equipment for use of the National Museum and the National Zoological Park. Inventory value of property $95,015.24 3,332.40 5,043.43 11,609.65 5,507.14 180,938.87 27,238.53 83.25 38,426. 29 5.61 2,789.17 • 2'4 22,492.91 25, 280.96 2,450.87 3,973. 76 224 PUBLIC HEALTH SERVICE Transferred to Treasury Department Drugs and chemicals, surgical supplies, office supplies and equipment, small hardware, plumbing and electrical supplies, as well as emergency relief material for first-aid use for the United States Coast Guard, Bureau of Internal Revenue, Bureau of Printing and Engraving, and the chief clerk's office. War Department Yarn, coffee urns, burlap bags, and a wood-carving machine. Total Inventory toorty value property $19,269.33 12,548.64 456,006.27 Sales To State and charitable institutions At auction Grand total 118,951.12 30,834.01 $605,791.4G CONSTRUCTION AND REPAIR During the year no important new construction was begun. Legislation was enacted, however (Public, No. 244, 69th Cong., H. R. 9875, approved May 18, 1926), whereby -Windmill Point was obtained from the Lighthouse Service as a site for the proposed new marine hospital in Detroit. The new location is ideal, situated on the water front at the entrance to the straits just above Belle Isle. A limit of cost for this hospital was fixed by the Congress at $600,000. (Public. No. 492, 69th Cong., H. R. 13040, second deficiency bill, approved July 3, 1926.) The appropriations for new quarters for medical officers, pharmacists, nurses, and attendants at the Chicago marine hospital were increased to $233,000, and an additional sum of $184,000 was appropriated for extension to power house, the modernization of mechanical equipment, additional facilities, and general repairs. The inadequate funds available for the construction of doctor's quarters at the Savannah marine hospital were also augmented by an additional $8,000, all by the act last above referred to. At Baltimore the hospital heating system was remodeled and the sewerage system was connected with the city sewer. At Boston a building was remodeled to provide additional housing facilities for personnel and a fire pump was installed. At Fort Stanton the dental office, X-ray laboratory, and library were rehoused in building No. 8, completely remodeled for the purpose. At Memphis additional bathing facilities were provided in all wards and the junior medical officers' quarters were enlarged. At New Orleans steam heat was extended to one large ward and a small frame isolation unit was constructed. At Poland, Me., new lighting fixtures were installed throughout, verandas on second and third floors were glassed in, toilet facilities were increased, male attendants' quarters were remodeled, and a nurses' call system was installed. It is also planned to increase the ward space there by remodeling the main hospital building. At Stapleton a small addition was built to the junior medical officers' quarters and an electrical mortuary refrigerator was installed in the hospital basement. At Savannah two verandas were glassed in, and a third veranda was converted into a three-bed ward PUBLIC HEALTH SERVICE 225 and private room. At St. Louis a new heating system was installed. At San Francisco new roofs were installed on four buildings, and ward No. 7 was altered and remodeled to provide for the installation of new X-ray equipment. At the National Leper Home at Carville, La., a new dairy barn was constructed, new electric-power lines were laid from the power house to the physiotherapy building and dairy, and the interior of 37 buildings and exterior of 20 buildings were painted by the station force. The grounds at Baltimore, Boston, Buffalo, Fort Stanton, Louisville, Memphis, Pittsburgh, St. Louis, and Carville were beautified by the addition of shrubs and trees secured in many instances without expense to the Government. The present major needs of the various hospitals are summarized as follows: New Orleans and San Francisco.—Extensive new construction, especially to replace old frame structures with fireproof wards, to modernize and enlarge each hospital to a capacity of 500 beds. Carville.—An infirmary building, detention facilities, and a recreation building. Stapleton.—Replacement of temporary frame surgical unit and enlargement of the hospital to 500 beds. Baltimore.—Fireproof buildings to replace old frame wards, additional nurses' quarters, and enlarged patients' dining room and kitchen. Buffalo.—Extension of ward space to enlarge the hospital to 100 beds, and quarters for nurses and officers. Fort Stanton.—A modern surgical unit and infirmary building, and additional quarters for personnel. Pittsburgh and Portland.—Quarters for nurses, medical officers, and attendants. Mobile.—A 50-bed extension to the hospital and a nurses' home. St. Louis.—A modern 50-bed ward to replace old frame structures. Evansville.—Nurses'/quarters and a surgical operating room. Seattle, Wash., and Galveston, Tex.—New marine hospitals. Inspection Engineer D. C. Trott, detailed from the office of the Supervising Architect, is in charge of construction and repair work. ABSTRACTS OF FIELD REPORTS A tabulated statement of the medical services given at marine hospitals and other relief stations is found on page 243. The briefest summary possible is given below of the detailed annual reports received from all stations. Marine Hospital No. 1, Baltimore, Md.—Surg. M. H. Foster in charge. The bed capacity of this hospital, 167, was fully utilized, especially during the winter and early spring, when beds were erected in the smoking rooms and all other available places to provide the facilities required. The number of admissions increased last year by about 10 per cent, although the number of hospital days was not increased. Intravenous injections of the arsenicals for the treatment of syphilis numbered 2,184, and there were 6,059 surgical operations performed, the resident staff being assisted when necessary by local attending specialists. The transactions of the out-patient office increased, the number of treatments exceeding 14656-26 16 226 PUBLIC HEALTH SERVICE that for the preceding year by 4,000, and the physical examinations by 800. A nurses' call-bell system was installed in the hospital. Markle Hospital No. 2, Boston (Chelsea), Mass.—Senior Surg. J. 0. Cobb in charge. The character of the principal classes of patients admitted to this hospital during the year was as follows: Merchant seamen, 888; foreign seamen, 63; Coast Guard men, 294 Employees' Compensation Commission, 61. The total number of patients treated was practically the same as last year. This hospital is particularly well equipped for handling patients of the Employees' Compensation Commission, as it possesses facilities for the care of both male and female patients. Marine Hospital No. 3, Buffalo, N. Y.—Surg. J. W. Trask in charge. This hospital, with a rated capacity of 60 beds, had a daily average of 61.8 patients during the year, additional beds being placed in the wards, on the porches, and in the corridors. The average duration of stay of patients was 30.02 days. There were performed 3,731 surgical operations, of which 215 were major. There were 980 dental treatments for inpatients and 3,338 dental treatments for out-patients. Owing to the almost constantly overcrowded condition of this hospital, which is utilized extensively by the United States Veterans' Bureau, as well RS by the Employees' Compensation Commission, it is evident that it should be enlarged by the construction of an additional wing. The Veterans' Bureau has recently requested that between 60 and 75 beds be made available for its patients when practicable. All patients except those acutely ill have been eliminated, admission being secured in many instances to the Sailors' Snug Harbor on Staten Island, New York City, or to soldiers' homes or other institutions furnishing domiciliary care. Marine Hospital No. 5, Chicago, Ill.—Surg. R. M. Grimm in charge. ,As heretofore, this hospital, like other marine hospitals, has been conducted as a general medical and surgical hospital, with a ward for tuberculosis and one or two wards for venereal diseases. The surgical service was ,active, a large number of surgical operations being performed and 9,514 postsurgical dressings applied. The dentist furnished 2,039 dental treatments to hospital patients and outpatients. The acute character of the service in this hospital may be seen from the fact that 16,106 trays were served to bed patients. The physiotherapy department was operated by two aides, working under the supervision of a medical officer; new equipment was added and a total of 11,093 treatments given, of which 7,603 were for hospital patients and 3,490 for out-patients. The clinical laboratory, conducted under the immediate supervision of a medical officer, made 5,712 examinations, including Wassermann, blood chemistry, and minor routine work. In the X-ray department 2,169 exposures were made for 1,366 patients. The American Medical Association has placed this hospital on the list of institutions approved for the training of internes. Out-patient offices are located, respectively, at 563 Lake Shore Drive, Federal Building, Van Buren Street post office, and the hospital proper. The number of physical examinations has increased, largely because of Coast Guard recruiting and the new requirement for food handlers on Lake vessels. The hospital also provides office and administrative facilities for the medical director of the third district and the district engineer. Important new construction and PUBLIC HEALTH SERVICE 227 major repairs, authorized by recent legislation, are discussed on page 224. Marine Hospital No. 6, Cleveland, Ohio.—Surg. L. P. H. Bahrenburg in charge. This hospital operated this year, as last, practically at capacity, and there was no increase possible in the number of patients, except in the out-patient office, where the work increased approximately 9 per cent, due in part, presumably, to the improved facilities in its new location in the United States Parcel Post Building, which is nearer the docks than the former location. There was, however, a marked increase in the amount of surgery performed, 19.36 per cent over last year and 114.5 per cent since 1923. There was an increase in laboratory procedures of 53 per cent over last year. The acquisition of a site for the new marine hospital is progressing satisfactorily, and it is believed that new construction will shortly be initiated. Maxine Hospital No. 7, Detroit, Mich.—Surg. J. S. Boggess in charge. A complete canvass of all hospital facilities available in Detroit shows that it is impossible to secure beds in contract institutions for the care of beneficiaries of the service during the erection of the new marine hospital proposed for this port. It will therefore be necessary to continue the present marine hospital in use as long as possible, or at least until construction is well underway. The Director of the United States Veterans' Bureau has asked that the capacity of this new hospital be such as to accommodate from 50 to 60 of his patients who, because of the numbers of seamen beneficiaries, are now not always able to obtain admission. The proposed capacity of the hospital has therefore been increased to meet the requirements of the Veterans' Bureau. • The hospital was almost constantly filled to capacity and patients of the Veterans' Bureau constituted approximately one-third of the hospital clientele. There was a large number of surgical operations„ of which attending specialists performed a considerable proportion. Physiotherapy treatments numbering 14,843 were given, a large amount of this work being devoted to out-patients of the United States Veterans' Bureau. • Marine Hospital No. 8, Evaxnsville, Ind.—Surg. Carl Ramus in charge. This is a small, general hospital with tuberculosis wards. Approximately one-half of the clientele are patients of the United States Veterans' Bureau, many of whom are admitted for a period of observation for diagnosis. The Employees' Compensation Commission also utilizes this institution freely for the care and examination of injured, Federal employees. More than 1,000 examinations in connection with the care of patients and diagnosis of conditions were made in the clinical laboratory of the hospital. Marine Hospital No. 9, Fort Stanton, N. Mex.—Surg. J. W. Tappan in charge. This sanatorium, reserved exclusively for tuberculosis patients, is excellently located for the purpose in the south central part of New Mexico. The summers are never oppressively hot, and the winters, with sunny days, low humidity, and clear cold air, are ideal. It is situated at an altitude of 6,230 feet above sea level, at a latitude approximating that of San Diego, Calif. Considerable care is exercised in the selection of patients, and only those who are ambulatory and otherwise meet the requirements of hospital 228 PUBLIC HEALTH SERVICE division circular No. 218, July 12, 1922, are transferred there. The rated capacity is 236 patients. Direct solar therapy was continued in use on 37 patients, chiefly -those having involvement of the bones, joints, and superficial tissues. The gradual exposure method of Rollier was used, a canvas sun shade being adjusted to allow partial exposure. All cases of bone, joint, and glandular tuberculosis showed improvement, and generally favorable results were obtained in the other cases selected for this treatment, which is not, however, considered specific nor of more than auxiliary therapeutic aid. Artificial heliotherapy was used extensively, 1,575 exposures to the various lamps being made. The importance of the eye, ear, nose, and throat department is evidenced by 3,271 throat treatments, not including heliotherapy treatments for tuberculous larynx, 779 special treatments of the eye, and 1,037 of the nose. Artificial pneumothorax was administered to 10 patients, 8 of whom had complete compression and 2 partial 232 fillings were given. The routine work performed by the dental officer, exclusive of formal operations, dentures, and miscellaneous procedures, is tabulated below: Number of new patients Number of sittings Hours operated Prophylactic and other treatments (hours) Alloy fillings and restorations Silicate cement fillings 196 2,290 1,592 707 721 101 One hundred seventeen patients were treated by occupational therapy, and the practice was continued of furnishing light employment to convalescent patients to test improvement and prepare for •discharge. Twenty-six were so employed during the month of June. Considerable time and attention were devoted to diversion and recreation as therapeutic measures. A radio outfit with individual receiving sets was installed in the infirmary wards and loud speakers were supplied to recreation rooms, thus affording diversion, particularly for patients confined to bed and unable to attend the moving pictures which are shown twice weekly. Two chaplains, Catholic and Protestant, respectively, have been on duty during the year. The Y. M. C. A. and Knights of Columbus maintain their secretaries at the station, and the latter organization finances, without expense to the Government, the moving-picture shows. The Seamen's Church Institute has continued its secretary on duty and contributed generously to welfare work. The station was supplied from its own resources with all milk and beef used at the station, approximately one-third of all the eggs consumed, and all pork products, including cured hams, and bacon. In addition, hides to the value of $818.25 and livestock to the value of $8,475 were disposed of by public auction. One hundred twentyone beef and dairy animals, valued at $7,180, were transferred to the National Leper Home, Carville, La. The number of cattle on hand at Fort Stanton at the end of the fiscal year was 1,100. Marine Hospital No. 10, Key West, Fla.—Surg. M. K. Gwyn in charge. Reflecting the increase in shipping that has occurred in practicaly all our southern ports, the functions of this hospital have been considerably increased. The number of in-patients more than doubled between 1923 and 1926. There was at the same time a 229 PUBLIC HEALTH SERVICE decrease in the per diem cost, which in this small hospital varies considerably with the number of patients under treatment. The Naval Hospital at this port was closed during the last fiscal year, and naval patients requiring hospital care are, at the request of the Navy Department, admitted to this marine hospital. Officers and men from the Army are likewise admitted upon request, the military hospital also being closed. Marine Hospital No. 11, Louisville, Ky.—Surg. E. H. • Mullan in charge. This hospital was well filled during the year, 80.9 per cent of all patients being patients of the United States Veterans' Bureau. The staff of attending specialists, representing surgery, internal medicine, orthopedic surgery, neurology, neuropsychiatry, and eye, ear, nose and throat, are freely utilized. This hospital also has an attending specialist in special laboratory procedure, whose services are utilized in the performance of important autopsies and other complicated laboratory procedures. To promote economies„ the acting chief nurse performed the duties of dietitian, and, instead of a full-time technician, a clinical laboratorian has been employed at 75 cents per hour from three to five hours daily. Difficult and complicated X-ray procedures are performed by contract,. the hospital itself performing all routine work. Marine Hospital No. 12, Memphis, Tenn.—Surg. R. E. Ebersole° in charge. This hospital, which was constructed in 1884, is ideally. located on grounds beautified with shrubbery and trees, overlooking a broad sweep of the Mississippi River. While small, chiefly of frame construction, and lacking a suitably located operating room and other modern appointments, it has satisfactorily supplied the needs of the port, which, because of an increase in river shipping,. have been considerable, necessitating the placing of beds on porches several times during the year to accommodate the clientele. No patients of the United States Veterans' Bureau are treated here, the majority being seamen from river craft and patients of the Employees' Compensation Commission. There has been a marked increase in the number of physical examinations of civil service appointees, civilians for Army training camps, and employees of various local Government activities. Marine Hospital No. 13, Mobile, Ala.—SUrg. W. H. Slaughter in charge. Demands for relief continue in excess of the facilities. Overflow patients are treated either in the City Hospital, Mobile, by contract, or are transferred to other marine hospitals having vacant beds. There are three private rooms with individual baths for female patients or others requiring special care, and total facilities for 90 patients, usually apportioned, approximately, as follows: Medical Surgical Urological Eye, ear, nose, and throat Infectious Tuberculous Total 30 20 20 10 5 5 90 A total of 1,718 surgical operations were performed, and 1,639 dental sittings given. The clinical laboratory is well equipped and manned with a full-time laboratorian, working under the direction 230 PUBLIC HEALTH SERVICE of a medical officer. The X-ray laboratory was enlarged and remodeled' and modern equipment installed. The physiotherapy treatments. continued to increase, a total of 6,683 being given to both hospital patients and out-patients. The out-patient office is located down town conveniently near the shipping district. Hospital No. 14, New Orleans, La.—Surg. W. C. Rucker Marine ' in charge. This hospital has continued to function far in excess of its rated capacity throughout the year, 129,786 days' relief being given, of which 100,762 were furnished merchant seamen. The average daily census was 355.5, with peaks of 409 and valleys of 302. Old-line beneficiaries constituted over 93 per cent of patients. Overcrowding of patients on porches and in shelters never intended for human occupation has of necessity been continued. From standpoints of humanity and true economy it is imperative that this hospital, which is wholly unfitted to meet the requirements of a great and growing port like New Orleans, be replaced by a suitable and modern fire-resisting structure. At present it is almost wholly of wooden construction; many of the wards are heated by stoves; the fire hazard is very great; the power and heating plant is wholly inadequate; there is no refrigeration plant; and the layout of the hospital makes economical administration exceedingly difficult. The work of instructing junior officers in their professional and administrative duties has continued throughout the year, and from a small beginning in January, 1925, has now assumed the proportions of an officers' training school. While this has entailed much extra labor on the part of the medical officer in charge and his staff, the results have adequately repaid the effort. This was done without additional expense to the Government. Fifty-two staff meetings were held during the year. Of these, 12 were administrative, 12 clinical, and 28 literary. The following is a summary of the operations of the various departments: Surgical-911 patients treated, 186 major and 271 minor operations performed; medical-781 patients treated; tuberculosis69 patients treated; receiving-2,173 white and 528 colored; total of 2,701 patients admitted; urological, 1,383 patients treated; 2,592 doses of salvarsan administered; 780 operations performed, including 67 cystoscopies and 61 'spinal punctures; 3,596 bloods drawn for Wassermann reactions; 5,176 prostatic smears were made; eye, ear, nose, and throat-233 operations performed, 9,705 treatments given, and 118 refractions made; dental-15,349 sittings,,17,255 treatments, and 2,243 completed cases; laboratory-27,657 examinations, 46 antitetanic and typhoid vaccinations; radiological-3,247 exposures on 1,957 patients; physiotherapy-21,128 treatments. to 418 patients; consultant-1,107 consultations; out-patient-2,446 patients treated 4,689 times, 835 operations performed; dietary service-184,111 rations prepared and served. Physical examinations (other than examinations for treatment) were made of 6,152 persons, 4,121 by the hospital staff and 2,031 by the out-patient office. Many economies were effected during the year. Among these was the manufacture of 15,104 pounds of soft soap made by the materiel department from fats which would otherwise have been wasted. Careful surveys of diets and wastes have resulted in many savings. Per diem and ration costs have been maintained at the low rate of the previous year. 231: PUBLIC HEALTH SERVICE Marine Hospital No. 15, Pittsburgh, Pa.—Senior Surg. C. H. 2 per cent in the 1 Gardner in charge. There was an increase of 22/ in the number cent per 1 of decrease a but patients of number of hospital days, a condition noted at otherS marine hospitals and due to causes previously discussed. Patients of the United States Veterans' Bureau constitute 72.6 per cent of the clientele of this • hospital. The physiotherapy department of this hospital was enlarged and additional equipment was installed; 8,677 treatments were given. The out-patient office was moved from the hospital to the Federal Building, and its equipment and space were improved. A nurse employed by the Post Office Department devotes a portion of her time to the cooperative functions in this office. A large proportion of out-patient work is devoted to physical examinations of applicants for appointment in the civil service and for enlistment in the Coast Guard. • -Marine Hospital No. 16, Portland, Me.—Surg. G. Parcher in charge. A phenomenal increase in work occurred at this station, the number of patients increasing 63.5 per cent and the total days' relief almost 100 per cent. This was due chiefly to the increased use of the hospital by the United States Veterans' Bureau. There was a corresponding increase in the amount of surgery performed and in the clinical laboratory and X-ray work. A physiotherapy department was opened, with a trained aid in charge. Welfare activities of the hospital were conducted by the American Red Cross and various other organizations, including Legion posts and auxiliaries, Veterans of Foreign Wars, Knights of Columbus, and the Junior League, which provided entertainments and in various ways supplied comfort and cheer to the patients. Marine Hospital No. 17, Port Townsend,TVash.—Surg. F. H. McKeon in charge. This hospital is a wooden structure, built in 1895, when Port Townsend was an important port of entry in the Pacific Northwest. There was an increase in the volume of medical relief furnished during the year, although it is handicapped by its remoteness from the ports principally Seattle, which it serves. The hospital was practically always filled to its capacity of 100, and, in addition, it was necessary to maintain approximately 20 patients in contract hospitals in Port Townsend and Seattle. Efforts were fruitful in making suitable disposition of a number of chronic cases, thereby relinquishing more beds for patients having acute diseases. Manne Hospital No. 18, St. Louis, Mo.—Surg. A. J. McLaughlin in charge. The increase during recent years of the work at this hospital, particularly for seamen and patients of the Employees' Compensation Commission, is shown in the following table: Year 1923 1924 1925 1926 Total patients treated 1,003 1,420 1,306 1,186 OutHospitalpatient patient treatments days 18,206 20,506 20,757 21,226 2,051 4,099 3,778 4,922 Physical examinations 503 910 1, 154 1,007 • There was a corresponding increase in the amount of surgery and special treatments. The physiotherapy department furnished 5,587 treatments, of which 3,308 were for in-patients and 2,279 for outpatients. This hospital had the experience of a large increase in 232 PUBLIC HEALTH SERVICE the number of patients without a corresponding increase in the number of hospital days, the turnover being increased by a reduction in the average duration of treatment. Marine Hospital No. 19, San Francisco, Calif.—Senior Surg. W. J. Pettus in charge. This hospital, which is too small for the purpose, and the inflammable wards of which should be replaced with more commodious fireproof structures, was kept constantly filled. No increase in the hospital work proper can occur until the institution is enlarged. There were 4,998 intravenous injections of arsphenamine and kindred drugs. In the dental department there were 2,844 extractions alone. The X-ray department made 5,441 exposures, and the clinical laboratory 8,925 examinations. The physiotherapy department gave 45,436 treatments to 8,448 patients, as follows: Nature of treatment Massage Electrotherapy Hydrotherapy Thermotherapy Exercise Total Number treated Number treatments 2,479 1,853 684 2,593 839 13,985 11,840 2,889 12,453 4,269 3,448 45,436 The out-patient work was practically doubled. The Seamen's Church Institute was active in the welfare activities. An average of 30 men a month, chiefly those rejoining ships after illness, are provided with clothing. Last year 25 patients were sent to the Sailors' Snug Harbor, Staten Island, an institution devoted to the care of veteran seamen who require chiefly custodial care. The Knights of Columbus and various other organizations continue to distribute cigarettes, toilet articles, etc., for the comfort of all patients. Marine Hospital No. 20, Savannah, Ga.—Surg. J. W. Burkhalter in charge. This hospital, of fireproof construction, three and onehalf stories high, was built in 1906, the capacity being increased to 146 patients by the addition of a new wing in 1924. A physiotherapy section was installed and 5,176 treatments given during the past year; 1,458 surgical operations were performed, and 3,846 dental treatments given. Well-equipped clinical and X-ray laboratories are maintained with part-time specialists in charge of each. The cafeteria system of serving meals was instituted with satisfactory results. The out-patient office is located in the hospital building. Marine Hospital No. 21, Stapleton, Staten Island, N. Y.—Senior Surg. C. H. Lavinder in charge. This hospital was filled as usual to capacity, its overflow sometimes amounting to 200 patients being sent to the marine hospital at Ellis Island. Of a total of 3,470 hospital patients, 2,630 were merchant seamen from American vessels, 479 Coast Guard men, and 147 patients of the Employees Compensation Commission; the remainder belonged to various minor classes of beneficiaries. No increase in the number of patients was possible, but the equipment and appointments were somewhat improved and the hospital standards well maintained. The total number of hospital employees, including the medical officers, is 197, which allows only one for each 1.46 patients, or approximately one-half the average personnel employed in New York City in civilian hospitals. The out-patient office, pharmacy, and executive office have been relocated to improve the administration. The facilities for housing PUBLIC HEALIH SERVICE 235 personnel are unsatisfactory; surgical ward buildings of temporary construction and inflammable type should be replaced with fireproof buildings, and the hospital should be enlarged to 500 beds. The medical officer in charge believes that in undermanned hospitals standards may deteriorate almost imperceptibly under certain conditions and that the per diem cost, $3.93, is lower than is compatible with continued efficiency. He recommends that the personnel be augmented, and believes that $4.50 per day is not an excessive cost for the proper care of patients in this hospital. The following is a statistical summary of the transactions: Bed capacity Medical staff: Full time Part time Attending specialists, serving also Marine Hospitals Nos. 43 and 70 Dental staff, full time Total personnel, exclusive of medical staff 3,224 Admissions 246 Brought over from last year Deaths Autopsies Number of hospital days Average length of stay in hospital, days Average per diem cost Average cost of ration Operating expenses, total Surgical operations performed Arsphenamine injections given Physiotherapy treatments given X-ray exposures made Laboratory examinations made Dental treatments given Cases handled by hospital service department Books circulated, patients' library Religious services held Entertainments given for patients 288 12 2 10 2 181 3,470 89 41 97,507 28. 1 $3.93 $0. 545 $388, 367.93 1,603 2,001 34, 564 8,051 15,877 8,404 3,470 12,701 106 60 Marine Hospital No. 22, Vineyard Haven, Mass.—Surg. H. M. Manning in charge. This hospital is well located on high ground, overlooking the beautiful Vineyard Haven Sound. Although small, it is an important refuge for sick and injured seamen from vessels passing near the port in the ,great lanes of ocean and coastwise commerce. It is also freely utilized by the United States Coast Guard. This hospital is one of many showing a greater number of patients for the year with a smaller number of hospital days and a consequent lower average period of treatment per patient in hospital. The total expenditures at this hospital for the year amounted to $31,417.76. Marine Hospital No. 43, Ellis Island, N. Y.—Senior Sura. E. K. Sprague, chief medical officer. To accommodate the overflow of patients from the marine hospital at Stapleton, which is inadequate in size for the needs of the port, an increasing number of American seamen have been admitted until they now outnumber the detained immigrants. See graphs (Fig. 4 and Fig. 5) on pages 236 and 237. The hospital is at present confronted with the problem of admitting; large numbers of alien seamen from both American and foreign vessels who, having venereal or other communicable diseases, are now required by law to be confined to hospital while their ships are in port. „Tel:awl-EN d,411111.31 ANIMINEM=t PIMM/11114 eiall MEMO 1 EMT ME= MEM= EAM M BMX t iMMM EMW Al',, h, • g A-naL 0, N ME0142gNhgR ,q ZIMEMUMWTIOEPa4.4ROMMPRO4NWPW14 m ER ill 44 " 511 A b ME= Mil ilin ' ii1 HiPUnemdi s*gmkgigithigEdwgEmai lirink O 'TATE0,!rf.T.Agv e: MT7ii II ii iMn it EXMIXERMIMIME •' HI il p M ,AMEMMUVIMi.lUe,MMIA'IWAM11.10 HP[Aiii , 4. 13 mammmommmemEmmmoMMMEWEIMMWOMMMOWtHM AMEIMMOMMWEEHTEMIMIIMMUMAwit*AMyvy-AM M IMMWEMVIUMMHIMMUIMIIMMWAVORW526M6ZOMMEN MERIN 11111111thill iltWA104:01691.220WZMINIF5T, FAir Pr,,P.19M-1.,̀ 11.11111141111H111 110,VAKI/zzegangrammveramightia. " ANtOgbOW/40 1011 Me4512691pgpOPT4WIAMENNO leap 4 WelAWAVAR4M04*42**MINIMM g4 4210.4244p4C2f24NRAMWMPARIMUM 44 1 4 :Pie.'42.VIOAW".9915510X6076562WIMEMER Ati/ V41 .60010X14§0620EUKRAWKOMEENNE -' 05,V1409W6592Z9, 1594WWWWKW/4 , 2611111Mag --/6.004Nif W69199550024002WAYAMMIMME '70.1 MVKITAKOMM560100.42VAPKESNMEI e gm4mozgegoolv4regawmauFw .4 AMFAMMIAWAMPKWO . ENOMiii 'IMMIEWIMMIPIMMEMEWAT0WW04-..,:AMMO ''''XiAlUI- /44 4Wakit:WPWAPAROWFWVASigEollg A M. 'MMEM MKAIMM rAZA§IMEld mema=, • 4g,m ma IINgtg' 57 2F @ 5412Effik hng-P. maq0k qMEE Waig2ffg a mngiElor_T!m MAIM MMAgNMEMg MffiEMMEEN 'EURIMME PMEEMME REMEREE MMENWON OWEIMM WON&A4 mp yFjt m___ Mb ME E9LMEM F i•tTivi,migmg :11111WEPP” MEMffiggiMMEB MEM FR*06w_mmyR ammgrimummmum • 9'll* M4 gkiCit lMMEEMMMO i MEMMOMME signEvem. ili1:2 ammitikumm 0MMMMEOMM .AagEgumusim agigimeampam 21611mMeXEM • EM WOMMEMM 0 MEMMMIMMMEMMME M mmnism. m MOMIAmmMEMEimm X 119111amilm MMEMMENNEMMOIMM MM. MIME= MMEMMAMEM GOMM MOWEIMEMIMME gmaramma gsgmmEmummuumm 'Aillaillagl- ibANi 111111a111111 MIMI 11111111111111111 IIr AIPONFP= 1 MIN11191,111111111 1111111111111111111111 1111,0.1,v d'i Ataini ang r wrampllnai 1 1 Nip ph rdasi RiNtp , RI ' THE tia .ninewn: re: • a ti. 238 PUBLIC HEALTH SERVICE The surgical work has increased with the advent of large numbers of patients admitted for treatment rather than for diagnosis. A dental officer was added to the staff. The X-ray laboratory made 6.363 exposures, the clinical laboratory 31,944 examinations, of which 6,901 were Wassermann tests for syphilis. The physiotherapy treatments were classified as follows: Massage Electrotherapy Thermotherapy Exercise Total 1,287 747 3,102 873 6,009 A special problem exists here requiring service workers, speaking several languages, to convey information to aliens in their own tongue, to assist patients to communicate with relatives, to protect them from unscrupulous persons, to adjust perplexing social problems, and occasionally to supply material relief from distressing conditions. The problem of handling visitors alone is a large one. Ambulatory patients are taken to the general reception rooms to receive visitors and only the relatives of bedfast patients are permitted to visit wards, thus eliminating congestion so far as possible. The hospital buildings are in bad repair. A survey was made jointly by officials of the Immigration Service and a representative of this bureau and an estimate made of $184,150 for necessary repairs and improvements, which was submitted to the Commissioner General of Immigration on July 9, 1925, with a view to having it included in budget items for the Immigration Service for the fiscal year 1927. The Commissioner General, however, after consideration of the matter, advised the bureau that it was found inexpedient to include these items in his estimates. Marine Hospital No. 66, Carville, La. (National Leper Home).-Surg.(R) 0. E. Denney in charge. Since the Public Health Service assumed operation in 1921 of this institution (formerly the Louisiana Leper Home) 394 lepers have been admitted. In the last fiscal year 62 lepers were admitted, 25 absconded, and 13 absconders returned for readmission. Three patients were discharged from hospital, leprosy arrested and no longer requiring treatment, and one was deported by the Bureau of Immigration. Of significance, with reference to the manner in which leprosy is contracted, is the fact that in the hospital there are six veterans of the SpanishAmerican War,13 veterans of the World War,3 veterans discharged from the military service because of disability, and 1 retired veteran, a total of 23 lepers who have had military service, some having had foreign tropical service, where the disease was probably contracted. Seventy-five thousand surgical dressings were applied. Intravenous and intramuscular injections of mercurochrome, mercurophen, metaphen, bismuth, neosalvarsan, and tryparsamide have been continued in specific or experimental treatment. A total of 37,902 physiotherapy treatments were given. Chaulmoogra oil is being continued in a large group of patients. The building program is incompleted and funds are required, especially for the construction of an infirmary building and to provide detention for the leprous insane and for absconders. (The annual report of this station will be reprinted in PUBLIC, HEALTH REPORTS, Vol. 41, No. 46, November 12, 1926.) PUBLIC HEALTH SERVICE 239 Marine Hospital No.70,67 Hudson Street, New York City.—Sur(r. W. C. Billings in charge. Although fully equipped as a hospital in all matters except ward facilities, this institution is operated solely as a large out-patient office, with branch stations at the Barge Office, the Seamen's Church Institute, and in the general post office building, Thirty-third Street and Eighth Avenue. The bacteriological and Roentgenological laboratories, fully equipped and manned by trained technicians, the dental unit, with four dental officers and a dental mechanic, as well as the specialistic services in physiotherapy, eye, ear, nose, and throat, skin and syphilis, genitourinary diseases, surgery, medicine, orthopedic surgery, and mental and nervous diseases, are maintained at the hospital proper, to which patients requiring refined procedures in diagnosis and treatment are referred from the branch stations. A 24-hour ambulance service is maintained, the station acting as a distributor of patients to the marine hospitals at Stapleton and Ellis Island, respectively. It is desired to acknowledge the valuable cooperation of the Seamen's Church Institute, which continued to supply facilities for a branch out-patient office, at which also, in addition to routine work, first-aid instruction required by the Steamboat Inspection Service for applicants for ships' papers was given one hour daily five days per week by a service officer. The examinations in first-aid proficiency are given by a different medical officer at the Barge Office. Marine Hospital No. 82, Norfolk, Va.—Surg. A. D. Foster in charge. The work here increased both in hospital and out-patient office. The acute character of the hospital service is seen in the fact that the average duration of treatment for all classes of patients was only 15.5 days, although a tuberculosis ward is maintained in accordance with the general custom prevailing in marine hospitals. The various classes of patients are indicated below: United States Veterans' Bureau Employees' Compensation Commission United States Coast Guard Seamen and all other beneficiaries Per cent 2. 2 7.0 12. 1 78. 7 The clinical laboratory made 7,739 examinations, of which 1,931 were Wassermann tests for syphilis, all in connection with the examination and treatment of patients. The X-ray department examined 1,568 patients. It was moved from the basement to a more suitable location on the first floor of the main building and its equipment was improved. There were a large number of surgical operations, including major abdominal operations, such as appendectomy, gastroenterostomy, gastrostomy, and cholecystotomy. The professional relations of the hospital staff with the County Medical Society and local officers are such as to stimulate and maintain high hospital ideals. One meeting of the County Medical Society each year is devoted entil'ely to the United States Public Health Service. Relief Station No. 220, Cairo, 111.—Acting Asst. Surg. R. E. 4) Barrows in charge. Although the old marine hospital here (No. one-half and five of n exceptio the with has been closed since 1915, ,a months when it was reopened in 1919 for the care of ex-soldiers occupied are quarters the and operated is third-class relief station by the medical officer in charge and one other employee without 240 PUBLIC HEALTH SERVICE expense to the Government for fuel,light,gas,or water. The hospital reservation presents a neat appearance, care being taken to keep the grass mowed, trees, hedges and shrubbery trimmed, and lawn and drives in good condition. The principal classes of beneficiaries, chiefly out-patients, are seamen from river boats, an expansion in river traffic having occurred, and patients of the Employees' Compensation Commission whose responsibilities include injured men from construction gangs employed by the United States Government on near-by projects. Relief Station No. 245, Galveston, Tex.—Asst. Surg.(R) E. M. F. Stephen in charge. A large amount of medical relief is furnished here. The out-patient office, consisting of five rooms, is centrally located in the customhouse and in close proximity to the contract hospital. The number of physical examinations increased, but there was a, decrease in the amount of medical treatment, due chiefly to a reduction in the appropriation, necessitating the discharge of patients from the contract hospital at the earliest possible date and the transfer of others to the marine hospital at New Orleans. Approximately 35 patients were in the hospital at all times, and approximately 40 out-patient treatments were rendered daily. Eight hundred forty-one patients were treated for venereal disease, and 1,939 intravenous treatments with neoarsphenamine were given. The contract hospital assigns for the exclusive care of service beneficiaries certain wellequipped wards connecting with consultation and treatment room, rest room, and other conveniences. The entire medical staff of the hospital is available for consultation and other assistance without compensation. Physical examinations continue to be made of the crews of Shipping Board vessels, and applicants are examined and instructed in ship sanitation and first aid. Medical advice by radio was furnished to ships at sea. The agreeable relations enjoyed by the station with the city, county, and State health departments, and civic organizations were maintained throughout the year. The station is represented in the Galveston Federal Business Association, which was recently organized. Relief Station.No. 258, Jacksonville, Fla.—Surg. J. G. Townsend in charge. During 1926 quarantine and relief functions were combined in this port by removing the quarantine station from Mayport, Fla., to a point immediately below the city. A full-time medical officer now performs all service functions in the port, with an anticipated economy in expenditures and improvement in character of service. Relief Station No. 266, Los Angeles, Calif.—Surg. R. H. Heterick in charge. Although the hospital work was decreased by diversion of a part of these activities to the relief station at San Pedro, a phenomenal increase in out-patient treatments has occurred, as set forth below: 1923 Out-patients treated Number of treatments Physical examinations 245 662 698 1924 333 865 936 1925 299 826 881 1926 1,665 3,872 2,233 PUBLIC HEALTH SERVICE 241 The medical officer in charge also supervises the first-aid station for Federal employees maintained by the Post Office Department at the arcade post office, where more than 2,000 out-patient treatments were given, not included in the above tabulations. Relief Station No. 270, Manila,P.I.—Surg. H. F. Smith in charge. In the Philippine Islands service beneficiaries are given out-patient relief at three ports of entry, namely, Manila, Iloilo, and Cebu. Hospital relief is furnished only at the port of Manila. The outpatient offices are located in the several quarantine offices—at Manila and Iloilo in the customhouse and at Cebu in the quarantine building; on the water front. The relief is supplied by the medical officers assigned to quarantine stations in addition to their other duties. Medicines and supplies were obtained from the supply depot of the service. There were 1,270 treatments given to 817 out-patients and 172 hospital patients were given an aggregate of 4,905 days' treatment. Physical examinations were made for the Bureau of Pensions, the Coast and Geodetic Survey, the Veterans' Bureau, and the Employees' Compensation Commission; also the complete physical examinations required by the Philippine government were made of all applicants for licenses as officers of vessels registered in the Philippine Islands. Relief Station No. 278, Milwaukee, -Wis.—Acting Asst. Surg. Robert J. Bach in charge. In addition to its local relief activities this station supervises the relief at 21 Coast Guard stations and 32 lighthouses. Its functions are fairly representative of those at the largest relief stations. By transferring 112 patients in need of hospital care to the marine hospital in Chicago the station was able to operate on restricted allowances. The medical officer in charge devoted 157 hours to giving required instruction in first aid to 68 pilots and other ships' officers applying for license, and made 395 calls at the contract hospital in connection with the care of service beneficiaries. Relief Station No. 305, Philadelphia, Pa.—Senior Surg. W. G. Stimpson in charge. More than one-fifth of all patients were injured Federal employees sent by the Employees' Compensation Commission and nearly one-half of the surgical operations- performed were for this class of beneficiaries. Merchant seamen, however, continue to constitute the major class of patients. Restriction in station allotments made it necessary to transfer all hospital patients able to travel to the marine hospitals in Baltimore and New York, thus reducing expenditures for contract hospital care. Relief Station No. 309, Port Arthur, Tex.—Surg. A. R. Sweeney in charge. The medical officer in charge of this relief station also has charge of the United States quarantine stations at Sabine, Tex., and the Lake Sabine district quarantine station, common administrative offices being located in the Federal building. Although merchant seamen from American vessels constitute more than 90 per cent of the clientele, other classes of beneficiaries treated during the year included foreign seamen, Coast Guard men, lighthouse keepers, patients of the Employees' Compensation Commission, and, as examinees, pilots, applicants for the citizens' military training camps, civil-service employees, and alien seamen. Relief Station No. 326, San Juan, P. R.—Surg. 0. H. Cox in charge. This is a combined relief and quarantine station, with one medical officer in charge of all activities. The work of the United 242 PUBLIC HEALTH SERVICE States Veterans' Bureau was separated during the year, but cooperative relations are maintained. The principal beneficiaries are now merchant seamen, civilian employees from United States Army vessels, personnel from the vessels of the Coast and Geodetic Survey, and from the Lighthouse Service, and patients from the Employees' Compensation Commission. Venereal disease heads the list of disabilities. It is desired to acknowledge the courtesy of various steamship companies whereby, in accordance with a not uncommon custom, many ships' patients were given free transportation to various ports of the United States when needing further treatment in marine hospitals. Relief Station No. 355, San Pedro, Calif.—Surg. H. A. Spencer in charge. There was a very great increase in the clinical work at this station over the previous year, as indicated in the following table: 1925 Total number of patients treated Total number treated in hospitals Died Number of days of relief in hospital Number of patients furnished office relief Number of times office relief was furnished Number of physical examinations 2,425 5 1 6 2,420 4,478 600 1926 3,890 336 9 3,552 3,554 9,054 618 The amount of local contract hospital care was reduced by the transfer from time to time during the year of 75 patients to the marine hospital in San Francisco when beds were available there and the station was thus enabled to operate on a restricted allotment. Relief Station No. 339,Washington, D. C.—Surg. G. L. Collins in charge. This station, well located in the Post Office Department Building, handles a very large amount of work for the Employees' Compensation Commission, the majority of patients being injured Federal employe.es. Of the 7,065 persons given physical examinations, 4,625 were civil-service applicants. The clinical laboratory made 1,766 examinations, of which 580 were Wassermann blood tests. The X-ray laboratory made 2,313 exposures. Supply Station, Perry Point, Md.—Associate Medical Purveyor C. H. Bierman in charge. The stock of the supply station consists of Army surplus supplies and other material for hospital and dispensary use purchased from time to time to apply on requisitions. Certain pharmaceutical preparations are made here at a saving in costs. Items of supplies or equipment are never purchased until it has been ascertained whether there is a reasonable substitute in the surplus stock. During the year a considerable portion of the surplus stock was transferred to other governmental agencies, in order to prevent possible deterioration and to relieve the service of the care of supplies in excess of normal requirements. Based on the total value of supplies received and shipped, the station was operated at a cost of $0.0657 on the dollar. 243 PUBLIC HEALTH SERVICE TABLE 1.-Number of patients treated annually, 1868 to 1926 i Fiscal year Prior to reorganization: 1868 1869 1870 After reorganization: 1871 1872 1873 1874 1875 1876 1877 1878 1879 1880 1881 1882 1883 1884 1885 1886 1887 1888 1889 1890 1891 1892 1893 1894 1895 1896 Sick and disabled patients furnished relief 11,535 11,356 10,560 14,256 13, 156 13, 529 14,356 15,009 16,808 15, 175 18,223 i 20,922 24,860 32,613 36, 184 40, 195 44, 761 41,714 43,822 45,314 48,203 49,518 50,671 52,992 53,610 53, 317 52,803 52,643 53,804 Sick and disabled patients furnished relief Fiscal year After reorganization-Continued: 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910--11 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 2 1924 1925 1926 54,477 52,709 55,489 56,355 58,381 56,310 58, 573 58,556 57,013 54,363 55,129 54,301 53,704 51,443 52,209 51,078 50,604 53,226 55,782 58,357 64,022 71,614 79,863 110,907 144,344 153,633 126,956 159,686 204,944 245, 140 activities of the service, I These figures do not include patients treated in connection with veterans' relief 3,414; 1925, 4,300, as follows: 1918, 192; 1919, 13,856; 1920, 279,036; 1921, 667,832; 1922, 242,379; 1923, 9,704; 1924, and 1926, 3,749. one calendar than in more treatment for 2 In this year the practice of recounting out-patients applying month was discontinued. other relief staTABLE 2.-Transactions at United States marine hospitals and tions, fiscal year 1926 Station and location Grand total FIRST-CLASS STATIONS MARINE HOSPITALS 1. Baltimore, Md 2. Boston, Mass 3. Buffalo, N. Y 5. Chicago, Ill 6. Cleveland, Ohio 7. Detroit, Mich 8. Evansville, Ind 9. Fort Stanton, N. Mex 10. Key West, Fla 11. Louisville, Ky 12. Memphis, Tenn 13. Mobile, Ala 14. New Orleans, La 15. Pittsburgh, Pa 16. Portland, Me 17. Port Townsend, Wash 18. St. Louis, Mo 19. San Francisco, Calif 20. Savannah, Ga 21. Stapleton, N. Y 22. Vineyard Haven, Mass 43. Ellis Island, N. Y 66. Carville, La 70. New York City, N Y_ Total numher ,of P"tients treated Pa• tents reNumber tents Died ing relief in in hos- hospital treated pital in hosJune pitals 30,1926 Number of 248,889 42,290 872 1,389 1,567 759 959 1,165 893 210 409 330 43 38 16 35 23 15 5 24 6 12 7 19 45 21 19 21 14 76 23 89 9 67 29 6,224 4,531 3,810 34,517 3,868 2,613 330 1,193 1,169 1,318 1,009 3,250 6,732 1,512 1,083 1,239 1,186 11,134 Z 761 5,202 435 9,099 990 23.829 1,000 684 921 2,952 751 587 963 519 2,688 877 3,470 215 8,500 319 Num- Numher of her of times pao ice tentsyff relief furnished was furoffice relief nished 3,420 1,321,309 206,599 575,139 138 102 53 123 76 60 33 231 27 46 31 82 318 45 43 90 53 269 76 259 13 383 259 54,884 4,835 19,793 48,949 2,964 7,854 22,564 3,091 13,258 43,719 33,558 66,614 27,570 2,703 7,245 25,588 1,720 5,747 373 120 14,338 784 3,095 82,669 839 1,398 9,240 318 1,058 16,846 884 325 14,201 28,953 2,329 9,166 129, 786 3,780 15,654 761 2,543 18,752 496 1,072 16,397 887 276 33,371 667 4,922 21,226 104,631 8,446 29,435 41,299 1,884 5,483 97,503 1,732 4,982 373 220 8,540 779 599 116,043 945 671 94,359 23.829 100.919 Number of cal examinations 91,553 2.803 3,233 1,455 1,861 1,401 2,074 86 180 83 358 278 2.426 8,571 806 413 102 1,007 2,300 343 251 45 227 9 12.489 244 PUBLIC HEALTH SERVICE TABLE 2.-Transactions at United States marine hospitals, etc.-Continued PaNum- Numtients ber of ber of Numre-n. Number patimes her of mai of days' tients office physits ing relief in furrelief cal exp' treated ted Died in hostitients hospital nished was aminain a hospital treated office furtions pitals June relief nished 30, 1926 Total numbern of Station and location • ber of FIRST-CLASS STATIONS-Continued MARINE ru)sPrrALs--continued • 82. Norfolk, Va Contract overflow hospitals 7,617 186 2, 196 186 35 8 136,877 34,509 699 ' 412 61 86 104 304 201 823 53 68 208 425 54 71 11 98 28 351 32 940 703 296 159 799 675 • 6 29 123 • 156 425 60 172 247 56 178 4,380 64 538 81 • 79 69 90 • 15 868 • 615 • 939 183 1,176 • 38 • 24 2,670 • 238 • 39 1,891 111 37 1,004 81 208 219 112 67 366 1,176 371 27 118 397 64 11 13 29 55 28 373 9 Total.. 152 46 62,302 5,421 17,055 ' 10,390. 2,867 3,008 1,150,785 102,368 314,879 45,668 SECOND, THIRD, AND FOURTH CLASS STATIONS, ETC. 255. Aberdeen, Wash 200. Albany, N. Y 201. Apalachicola, Fla 202. Ashland, Wis 203. Ashtabula, Ohio 204. Astoria, Oreg 301. Balboa Heights, Canal Zone 207. Bangor, Me 208. Bay City, Mich 209. Beaufort, N. C 210. Bellingham, Wash 212. Biloxi, Miss 213. Boothbay Harbor, Me 215. Bridgeport, Conn 217. Brunswick, Ga 219. Burlington, Iowa 220. Cairo, Ill 221. Cambridge, Md 223. Cape May, N. J 224. Charleston, S. C 226. Cincinnati, Ohio 229. Cordova, Alaska 230. Crisfield, Md 234. Duluth, Minn 236. Eastport, Me 237. Edenton, N. C 238. Elizabeth City, N C 352. El Paso, Tex 239. Erie, Pa 240. Escanaba, Mich 241. Eureka, Calif 235. Everett, Wash 243. Fall River, Mass 244. Gallipolis, Ohio 245. Galveston, Tex 246. Georgetown, S. C 247. Glouwster, Mass 248. Grand Haven, Mass 249. Green Bay, Wis 250. Gulfport, Miss 251. Hancock, Mich 252. Hartford, Conn 254. Honolulu, Hawaii 359. Houston, Tex 258. Jacksonville, Fla 260. Juneau, Alaska 262. Ketchikan, Alaska 263. Kodiak, Alaska 264. La Crosse, 'Wis 242. Lee Hall, Va 265. Lewes, Del 346. Little Rock, Ark 266. Los Angeles, Calif 268. Ludington, Mich 269. Machias, Me 270. Manila, P. I 271. Manistee, Mich 272. Manitowoc, Wis 273. Marquette, Mich 274. Marshfield, Oreg _ 277. Menominee, Mich 347. Miami, Fla 278. Milwaukee, Wis 282. Nantucket, Mass 283. Nashville, Tenn 284. Natchez, Miss 285. New Bedford, Mass • 22 12 6 17 10 21 17 90 15 70 94 38 43 27 71 6 15 84 15 39 32 3 61 636 23 7 14 5 5 15 229 119 129 70 177 2 2, 1 2 1 10 1 5 2 2 12 4 1 1 1, 2 2 2 2 3 5 3 1 '5 1 6 3 4 1 5 1 1 1 5 17 2 10 4 1 2 1 6 1 4 3 4 1 17 6 3 8 6 31 1 226 12 1,102 216 180 487 730 421 7,043 152 370 79 34 128 75 171 266 1,013 265 640 988 518 961 291 704 87 414 902 151 351 475 39 1,101 12,431 214 155 217 50 31 334 4,139 2,214 1,325 2,120 2,595 63 1 6 2 17 2 2 14 2 3 1 4 447 11 6,507 249 • 172 9 68 11 26 3 78 209 17 2 12 27 1 1 1 4,905 167 919 398 300 24 813 2,133 110 30 200 492 348 404 50 264 73 160 75 96 249 531 173 345 450 677 44 41 68 158 180 951 413 522 48 136 54 111 1 1 77 120 11 13 261 748 17 17 870 2,612 609 1,313 258 613 116 137 772 2,322 604 865 6 22 29 45 117 244 141 796 341 970 45 60 133 319 215 336 53 99 117 223 3,744 13,350 64 95 515 1,766 74 115 65 157 64 126 85 123 47 133 105 6 38 38 24 14 1,575 7 195 52 51 125 55 639 496 810 113 999 38 18 2,670 207 38 1,665 99 37 832 72 140 208 86 64 288 967 354 25 106 370 304 125 332 28 47 1 22 32 42 163 2,231 12 11 82cI 11, 21 64l 51r 115 4£3 64',; 3£; 7i) 1,I 6213 1,354 1,877 1,211 149 1,530 61 43 4,004 785 91 3,872 392 101 1,287 230 253 666 136 174 523 2,161 474 52 195 661 32 134 11 32 302 1 64 1 28 529 19 14 13 13 1 36 235 194 242 4 283 9 1 245 PUBLIC HEALTH SERVICE TABLE 2.-Tran8actions at United States marine kospital.s, etc.-Continued Station and location Total numof , 4 ber , P'tients treated PaNumtients ber of repamaintients Died ing in hostreated in hospital pitals June 30,1926 Num- Number of ber . of Numpatimes ber of Number tients office physiof days' furrelief cal exrelief in nished was aminahospital office furtions relief nished SECOND, THIRD, AND FOURTH CLASS STATIONS, ETC. 286. New Bern, N. C 230 288. New Haven, Conn 68 477 289. New London, Conn 291. Newport, Ark 10 292. Newport, Oreg 72 293. Newport, R.I 251 294. Newport News, Va 221 295. Nome, Alaska 28 141 297. Ogdensburg, N. Y 298. Oswego, N Y 209 262 300. Paducah, Ky 306. Panama City, Fla 31 502 Pensacola, Fla 302. 75 303. Perth Amboy, N. J 46 304. Petersburg, Alaska 3,758 305. Philadelphia, Pa 45 307. Ponce, P. R 257 308. Port Angeles, Wash 1,265 309. Port Arthur, Tex 295 310. Port Huron, Mich 1,367 312. Portland, Oreg. 2 356. Portsmouth, N.H 419 314. Providence, R.I 315. Provincetown, Mass 99 ,: 127 316. Richmond, Va. 1,922 317. Rock Island, BI 157 318. Rockland, Me 18 320. Saginaw, Mich 113 319. St. Thomas, Virgin Islands 1 354. Salem, Mass 547 323. San Diego, Calif 42 324. Sandusky, Ohio 941 326. San Juan, P. R 3,890 355. San Pedro, Calif 829 327. Sault Ste. Marie, Mich.14,339 329. Seattle, Wash 66 331. Sheboygan, Wis 42 328. Sitka, Alaska 206 332. Solomons, Md 68 334. South Bend, Wash 331 361. Southport, N. C 287 335. Superior, Wis 298 345. Tacoma, Wash 899 336. Tampa, Fla 662 337. Toledo, Ohio 1 357. Unalaska, Alaska 381 338. Vicksburg, Miss 2,246 339. Washington, D. C 931 360. Washington, D.C.(dental clinic) 102 340. Washington, N. C 396 341. Whitestone, Va 143 362. Wilmington, Del 484 342. Wilmington, N. C 79 17 154 5 63 12 15 19 30 81 13 2 542 20 12 189 20 203 1 63 21 8 2 2 20 72 5 468 336 217 153 1 6 8 22 1 4 1 ______ 2 5 _ 2 8 3 36 684 1 90 412 159 358 19 1 5 4 2 13 - 2 1 1 -4 7 9 1 6 -- -- 1 19 11 11 7 10 1 2 131 4 1 3 6 5 2 8 5 98 160 3 5 76 24 110 1 21 7 62 -- 835 267 2,264 4 9 -- 883 262 9 5,088 217 69 1,546 162 3,825 11 726 275 94 27 10 335 151 284 51 143 323 427 10 30 67 164 188 280 221 284 16 60 126 274 190 635 232 917 48 31 421 1,355 62 103 44 147 3,216 12,180 25 29 245 393 1,076 3,264 275 834 1,164 2,920 1 1 356 578 99 237 106 300 1,914 7,397 155 282 16 40 93 149 1 1 4,478 475 651 44 68 37 23,818 473 845 3,552 3,554 9,054 2,199 612 1,696 4,035 14,186 17,016 2 65 146 69 63 36 73 198 285 87 132 46 33.1 597 1,087 211 373 259 274 450 1,535 789 1,042 1,792 531 1,154 21 951 283 765 2,086 19,898 2, 191 9,780 931 186 81 139 -1,710 396 52 136 374 432 422 1,245 48 152 73 11 19 48 4 39 39 30 52 35 4,286 6 99 127 179 985 1 266 41 79 2,148 45 30 478 20 441 618 99 10,614 30 2 14 40 9 99 379 208 68 7,065 17 11 40 223 MISCELLANEOUS Black Mountain, N. C. (Cragmont Sanatorium) Curtis Bay, Md Freeport, Tex New London, Conn.(destroyer force and academy) Philadelphia, Pa.(U.S. Coast Guard receiving unit) Washington, D. C. (St. Elizabeths Hospital) Contract physicians for U. S. Coast Guard and Lighthouse Service U. S. Coast Guard vessels Total Grand total 4 2,276 2 4 20,101 309 81 8 124 124 4,101 18,019 34 112,012 7,781 248,889 3 2 42,290 11 2 2 -13 1,095 42 -- 2,174 93 105 888 124 5 19,792 42,080 1,904 _._ 129 36 4,067 10,702 18,019 43,300 1,307 3,100 73 37,339 282 189 5,570 2,276 170,524 104,231 257,260 45,885 3,420 1,321,309 206,599 572, 139 91,553 412 TABLE 3.-Relief furnished at United States marine hospitals and other relief stations, fiscal year 1926, classified by beneficiary Beneficiary Class of station American seamen First-class stations Other relief stations Foreign seamen First-class stations Other relief stations U. S. Coast Guard First-class stations Other relief stations Coast Guard vessels Contract physicians Total Total Total U. S. Army First-class stations Other relief stations Total U. S. Navy and Marine Corps First-class stations Other relief stations Total Number Total of number patients of treated patients in treated hospita 1 Patients remaining Number of in days relief hospital in June 30, hospital 1926 Died Number of patients furnished office relief Number Number of of times office re- physical examilief was furnished nations 69,351 38,243 18,149 5,297 511 163 1,939 333 753,720 123,861 51,202 32,946 183,924 76,370 16,122 3,853 107, 594 23,446 674 2,272 877,581 84,148 260,294 19,975 791 200 576 107 7 4 37 5 15,293 2, 154 215 93 477 219 398 59 hj it21 991 683 11 42 17,447 308 696 457 8, 171 26, 771 18,019 4,032 3, 200 991 14 8 157 23 62,114 9,416 269 4,971 25, 780 18,019 3,999 13,414 57,978 43,300 10, 534 8,926 5,741 3,100 1,294 56,993 4,224 71,799 52,769 125,226 19,061 l•-•3 366 254 20 7 162 70 346 247 817 577 413 653 CP 620 27 2 232 593 1,394 89 77 44 15 2 680 130 45 62 4,174 149 15 17 166 59 2 2 810 107 323 32 206 182 155 44 4 4 2 4,656 308 51 138 178 234 16 2 33 22 180 1,0 Mississippi River Commission First-class stations Other relief stations 388 199 4 6 4,964 189 412 18 Seamen, U. S. Engineer Corps and Army Transport Service. First-class stations 1,318 648 9 54 23,142 670 2,070 60 Other relief stations 1,014 163 4 2,273 851 2, 361 28 2,332 811 58 25,415 1,521 4,431 88 Total Total 9 1:4 tij <1 8 tt U. S. Lighthouse Service First-class stations Other relief stations Contract physicians 17. S. Coast and Geodetic Survey First-class stations Other relief stations Total Total U. S. Employees' Compensation Commission. First-class stations _ Other relief stations U. S. Veterans' Bureau First-class stations Other relief stations Total Total U. S. Immigration Service First-class stations Other relief stations Total U. S. Public Health Service officers and employees. First-class stations Other relief stations Total Lepers First-class stations Other relief stations Total Pilots First-class stations Other relief stations U.S. Civil Service applicants and Post Office employees. First-class stations Other relief stations Total Total Bureau of Pensions First-class stations Other relief stations Total 6 2 28 11 8,895 2,496 13 648 645 68 1,527 1,571 168 157 13 8 400 1 42 1 59 39 11,404 1,361 3,266 284 114 461 5 7 1,377 957 72 402 156 1,076 90 423 575 101 2 12 2,334 474 1,232 513 38,963 8,282 1,461 574 13 4 108 22 40,848 8,534 37,502 7,708 87,786 41,635 4,264 4,733 47, 245 2,035 17 130 49,382 45,210 129,421 8,997 3,377 372 3, 150 306 69 4 188 79,735 19, 101 227 66 2,616 165 30 355 3,749 3,456 73 188 7,607 247 5,942 50 210 4 2, 781 293 98,836 _ 6,216 1,665 58,476 743 197 728 385 19 3 7,854 5,992 22 214 59,204 924 768 69 1,761 276 123 1 167 84 6,959 251 6,843 68 4,563 1,008 15,318 7,912 972 28 14 6,911 5, 571 23,230 1,000 259 94,387 1 6 3 2 94,387 1 6 14 5,061 1,013 498 5 12 6,074 503 12 326 325 29 326 325 29 259 .. 1,862 114 5 3,868 2,653 6,521 8,778 10,673 19,451 209 612 821 TABLE 3.—Relief furnished at United States marine hospitals and other relief stations, fiscal year 1026, classified by beneficiary—Con. Miscellaneous Class of station First-class stations Other relief stations Total Totals_ First-class stations Other relief stations Coast Guard vessels Contract physicians Grand total 213 12,008 23 6 Patients remaining Number of in days s relief hospital in June 30, hospital 1926 Died 3 2 457 146 Number of patients tit furnished office relief 190 12,002 Number of times ti office relief was furnished 200 12,268 Number of D physical • n exapiinations 1,223 11,405 12,221 29 3 2 603 12,192 12,468 12,628 136,877 89,892 18,019 4, 101 34,509 7,747 699 189 3,008 412 1, 150,785 170,242 282 102,368 82,145 18,019 4,067 314,879 203,258 43,300 10,702 45,668 41,478 3, 100 1,307 248,889 42,290 888 3,420 1, 321,309 206,599 572,139 91,553 34 amums IIIIVali Orland Beneficiary Number Total of number patients of treated patients in treated hospital 42 00 PUBLIC HEALTH SERVICE 249 TABLE 4.—Causes of admission for discharged patients and condition on discharge, United States marine hospitals and other relief stations, fiscal year 1926 Number having specified disease or injury 1 Disease or condition Major conditions for which ad. Mit Condition admittedon spedof arge patients fordischcifie disease or injury Total numCon- Conber of dition dition Segue- perNot lae.to sons Other " 5 Im• ond third • im- Died (=major having Cured proved proved imin im- in orconeach ditions specitance 3 w"on fled distance ease or injury •-•,..... .1.... A. ;+ , PS". Abnormalities and congenital malformations 8 8 1 15 32 Blood and blood-forming or2 28 gans, diseases and injuries of_ 53 7 16 Bones and cartilages, diseases 437 670 and injuries of 1,666 6 37 516 Circulatory system, diseases and injuries of: 1 196 1 59 79 Heart disease, valvular____ 336 239 58 12 645 47 64 1 30 142 217 Varicose veins 53 22 348 6 104 80 175 All others 713 . Communicable and infectious diseases, not including tuberculosis and venereal: Conjunctivitis, granular 10 13 1 trachomatous _ 3 38 24 11 1 5 14 7 13 Dengue 1 243 8 84 857 491 826 5 Influenza 26 139 2 91 63 37 5 338 295 1 Malaria 62 1 24 43 157 Rheumatic fever, acute__ 130 14 6 7 14 7 21 98 50 Typhoid fever 92 6 47 10 284 75 1 All others 417 91 71 47 Dental 209 Digestive system,diseases and injuries of: 12' 107 194 367 793 Appendicitis 680 98 15 62 195 1 2 161 475 421 Gastritis 43 11 2 8C 152 246 655 Hemorrhoids 480 134 41 217 27 412 502 7 1,165 All others Ear, nose, and throat, diseases and injuries of: 50 1 107 68 378 226 108 44 Deviation, nasal septum._ 90 2 1 51 27 263 171 1 69 22 Otitis media_ 222 556 2,578 1, 113 1,891 Tonsilitis 599 87 1 123 5 281 3 300 712 All others Endocrines, diseases and in51 1 8 9 86 155 juries of Eye and annexa, diseases and 10E /61 1 6 69 345 injuries of Genito-urinary system, diseases and injuries of (exclusive of venereal): 43 64 89 2 6 339 204 103 32 Nephritis 191 12 224 401 3 831 All others 241 265 10 6 723 1,630 1, 251 44 335 Hernia , Joints and burs,diseases and injuries of: 164 11 381 7 125 1, 151 236 67 160 688 Arthritis 113' 5 158 76 352 All others 29 33 4 66 Leprosy 66 Lymphatic system, diseases and injuries of: 815 181 90 611 205 9 40 Lymphadenitis 357 3 9 7 1 20 All others Muscles, fascite, tendons, and tendon sheaths, diseases and 244[ 2 503 381 1. _, 132 ___ injuries of __ 1 Except in the case ofspecific diseases,statistics are given only for the major condition for which admitted. 2 Represents number of discharges for each condition. 3 Where sequelae were given, no third diagnosis was recorded. NOTE.—This table does not include immigration patients discharged from U. S. Marine Hospital No. 43, Ellis Island, N. Y. • 250 PUBLIC HEALTH SERVICE TABLE 4.—Causes of admission for discharged patients and condition on discharge, United States marine hospitals and other relief stations, fiscal year /926—Continued Number having specified disease or injury Disease or condition Major Concon- dition ditions secfor im_ 4 ond which , ad- 'pormit_ tance ted Nervous system, diseases and injuries of: Epilepsy without psy47 chosis 245 Neuritis 426 All others _ 21 Obstetric and gyneocological conditions Parasitic diseases: 29 Uncinariasis 157 All others Poisonings and intoxications: Alcohol (ethyl) poison164 ing, acute Alcoholism, chronic (wi th61 out psychosis) 106 All others Psychiatric diseases: Drug addiction without 17 psychosis 316 All others Respiratory system, diseases and injuries of (exclusive of tuberculosis): 159 Asthma 859 Bronchitis 207 Pleurisy 280 Pneumonia 13 All others Skin and its appendages, dis783 eases and injuries of Tuberculosis: Tuberculosis, pulmonary_ 1,275 Tuberculosis (otherwise 85 - unclassified) Tumors: 163 Carcinoma 201 All others Venereal diseases: 949 Chancroidal infections_ __ _ 2,935 Gonococcus infections 1,940 Syphilis 35 All others 36 Inoculations 666 Under observation Miscellaneous: 254 Cellulitis 4,751 All others Total 33,275 Condition third in importance Total number of nerSenueOther Not to sons lae— Immajor having Cured proved im- Died conproved ditions each condition specifled disease or injury 30 61 122 6 63 350 1 50 69 8 15 132 196 7 10 2 29 12 80 9 43 13 75 1 1 7 37 4 185 62 71 2 29 1 66 10 55 35 34 1 3 2 13 14 20 1 33 6 105 10 9 10 159 244 1, 161 293 366 11 295 60 103 4 104 414 92 87 7 1 5 4 9 62 298 326 2 6 151 1 177 3 173 921 6 38 3 62 7 46 50 2 3 2 3 37 243 995 838 13 2 666 16 62 24 39 17 4 Condition on discharge of patients admitted for specified disease or injury 19 3 76 231 50 52 9 49 19 15 120 35 22 17 19 1,430 1 1 38 146 45 28 2 25 1 8 119 4 37 35 7 2 207 18 78 34 66 116 307 898 26 30 180 615 54 1,706 3,326 3,018 251 355 30 11 6 453 1,580 1,032 11 28 " 30 10 23 317 91 1,495 96 1,962 9 3 37 64 1,248 9,484 13,411 109 872 9,399 • PUBLIC HEALTH SERVICE 251 TABLE 5.—Causes of death in United States marine hospitals and other relief stations during fiscal year 1926 International list No. Cause of death Number of deaths PART I I. Epidemic, endemic, and infectious diseases 1 Typhoid and paratyphoid fever 5 Malaria 6 Smallpox 7 Measles 11 Influenza 16 Dysentery 20 Leprosy 31 Tuberculosis of the respiratory system 32 Tuberculosis of the meninges and central nervous system 33 Tuberculosis of the intestines and peritoneum 36 Tuberculosis of other organs 37 Disseminated tuberculosis 38 Syphilis 40 Gonococcus infection 41 Purulent infection septicemia 14 1 2 1 7 1 5 168 1 1 3 6 26 1 2 II. General diseases not included in Class I 43 44 45 49 50 57 58 60 65 66 Cancer and other malignant tumors of the buccal cavity Cancer and other malignant tumors of the stomach and liver Cancer and other malignant tumors of the peritoneum, intestines, and rectum Cancer and other malignant tumors of other or unspecified organs Benign tumors and tumors not returned as malignant Diabetes mellitus Anemia or chlorosis Diseases of the thyroid gland Leukemia and Hodgkins disease Alcoholism, acute and chronic 3 28 6 35 1 5 6 2 2 5 HI. Diseases of the nervous system and of the organs of special sense 70 71 73 74 75 76 84 86 Encephalitis Meningitis Other diseases of the spinal cord Cerebral hemorrhage,apoplexy Paralysis without specified cause General paralysis of the insane Other diseases of the nervous system Diseases of the ear and of the mastoid process 2 8 3 34 3 5 1 3 /V. Diseases of the circulatory system 88 Endocarditis and myocarditis 89 Angina pectoris 90 Other diseases of the heart 91 Diseases of the arteries 92 Embolism and thrombosis (not cerebral) 95 Hemorrhage without specified cause 96 Other diseases of the circulatory system 16 2 135 17 1 6 1 V. Diseases of the respiratory system 97 99 100 101 102 105 107 Diseases of the nasal fossm and their annexa Bronchitis Bronchopneumonia Pneumonia Pleurisy Asthma Other diseases of the respiratory system 1 2 28 66 6 3 3 V/. Diseases of the digestive system 108 Diseases of the mouth and annexa 111 Ulcer of the stomach and duodenum 112 Other diseases of the stomach 113 Diarrhea and enteritis 116 Diseases due to other intestinal parasites 117 Appendicitis and typhlitis 118 Hernia 119 Other diseases of the intestines 122 Cirrhosis of the liver 124 Other diseases of the liver 126 Peritonitis without specified cause 127 Other diseases of the digestive system (cancer and tuberculosis excepted) 14656-26----17 1 8 2 3 1 12 10 2 2 3 5 4 252 PUBLIC HEALTH SERVICE TABLE 5.—Causes of death in United States marble hospitals and other relief stations during fiscal year 1926—Continued International list No. Cause of death Number of deaths PAST I—Continued VII. Nonvenereal diseases of the genito-urinary system and annexa 128 129 131 132 133 134 135 Acute nephritis Chronic nephritis Other diseases of the kidneys and annexa Calculi of the urinary passages _ Diseases of the bladder Diseases of the urethra, urinary abscess, etc Diseases of the prostate 145 Other accidents of labor 21 41 2 1 1 2 2 V/11. The puerperal state 1 IX. Diseases of the skin and of the cellular tissue 151 153 154 Gangrene Acute abscess Other diseases of the skin and annexa 155 Diseases of the bones (tuberculosis excepted) 1 4 3 X. Diseases of the bones and of the organs of locomotion 1 XIV. External causes 171 178 179 182 183 185 187 188 201 202 Suicide by cutting or piercing instruments Conflagration Accidental burns (conflagration excepted) Accidental drowning Accidental traumatism by firearms (wounds of war excepted) Accidental traumatism by fall Accidental traumatism by machines Accidental traumatism by other crushing (vehicles, railways, landslides, etc.) Fracture (cause not specified) Other external violence (cause not specified) 205 Causes of death not specified or ill-defined 2 2 4 3 1 17 1 4 14 3 X V. III-defined diseases 10 872 Total PART II 7 9 31 65 78 90 91 97 100 117 149 171 Causes of death of immigration patients at U. S. Marine Hospital No. 43, Ellis Island, N.Y. Measles Whooping cough Tuberculosis of the respiratory system Leukemia and Hodgkin's disease Epilepsy Other diseases of the heart Diseases of the arteries Diseases of the nasal fossn and their annexa Broncho-pneumonia Appendicitis and typhlitis Following childbirth (not otherwise defined) Suicide by cutting or piercing instruments _ Total Grand total 3 1 2 1 1 2 1 1 1 1 1 16 888 TABLE 6.—Number of patients of each class's of beneficiary discharged from United States marine hospitals and other relief stations during the fiscal year 1926, by broad groups of conditions Group Total Abnormalities and congenital malformations Blood and blood-forming organs, diseases and injuries of Bones and cartilages, diseases and injuries of Circulatory system, diseases and injuries of Communicable and infectious diseases, not including tuberculosis and venereal _ Dental Digestive system, diseases and injuries of. Ear, nose, and throat, diseases and injuries of Endocrines, diseases and injuries of Eye and annexa, diseases and injuries of_ _ Genito-urinary system, diseases and injuries of (exclusive of venereal) Hernia Joints and bursm, diseases and injuries of. Leprosy Lymphatic system, diseases and injuries of Muscles, fasciw, tendons and tendon sheaths, diseases and injuries of Nervous system, diseases and injuries of... Obstetrics and gynecological conditions Parasitic diseases Poisonings and intoxications Psychiatric diseases Respiratory system, diseases and injuries çtf cexclU.SiVe. of tuberculosis) Seamen, U.S. U. S. Missis- Engineer Amensippi U. S. , g Navy ForeignCorps Coast `-'''-" and can River seamen seamen Guard Army and -- Marine CornCorp mission Army Trans-s port Service 17 53 36 1 1 1,666 1,060 34 109 1,191 805 7 80 1, 797 209 2, 309 1, 159 118 1, 501 49 8 48 317 53 335 3,437 155 345 1,746 96 203 29 5 688 11 42 1,035 1,251 1,040 66 777 769 660 1 7 10 14 90 61 110 U.S. IT. S. EmU. S. Coast ployees U. S. Com- Veter- Immiand ans' gration Geo- pensation Bureau Service detic Survey Cornmission V 9 32 U. S. Lighthouse Service 2 9 1 U. S. Public Health Service , ,„,„ Miscel• officers '-'''''''' laneous and employees 4 1.2 1 2 11 3 19 1 2 2 18 18 4 327 76 1 10 32 21 5 34 176 3 1 6 4 1 13 45 9 65 3 51 34 4 34 10 2 18 10 3 7 36 12 223 7 1 7 58 3 56 1 6 8 26 1 1 56 4 11 42 5 6 13 659 37 25 4 144 2 2 14 1 40 2 5 2 1 2 1 5 2 3 21 32 12 10 12 10 4 2 3 13 241 80 96 109 136 3 8 10 11 8 16 5 1 2 214 20 2 1 1 16 10 4 1 7 4 5 40 1 377 299 19 20 1 1 4 3 1,132 718 21 186 331 333 620 452 14 78 218 193 19 13 201 72 1 1 24 19 16 13 5 2 2 22 42 41 1 3 4 4 1 3 16 1,518 962 31 227 5 2 30 47 1 1 1 2 6 11 1 2 1 21 5 19 113 2 68 12 78 4 7 147 2 aDIMIHS FII-IVaH-Marl Class of beneficiary 1 65 1 1 1 1 C.4 TABLE 6.—Number of patients of each class of beneficiary discharged from United States marine hospitals and other relief stations during the fiscal year 1926, by broad groups of conditions—Continued Group Total Skin and its appendages, diseases and injuries of Tuberculosis Tumors Venereal diseases Inoculations Under observations Miscellaneous Total cases Seamen, U. S. U. S. EmU. S. U. S. Missis- EngiU.S. Coast ployees U. S. neer Ameri- Foreign U. S. U. S. Navy sippi Lightand ComCorps VeterCoast Army and can River and house Geo- pensa- ans' Marine Com- Atmy seamen seamen Guard Service detic tion Bureau Corps mission TransSurvey Commission portee 216 3,072 16 14 3 156 23 13 109 151 38 26 607 9 126 520 21, 185 637 4,008 783 1,360 364 5,859 36 666 5,005 504 828 274 4,507 33,275 U. S. Public U. S. Health Immi- Service Miscelgration officers Lepers laneous Service and employees 2 4 4 3 19 22 15 9 144 15 5 5 35 5 2 15 19 9 3 4 39 428 32 191 1 6 1 170 1 11 5 19 6 117 5 49 3 17 25 774 254 250 5 11 9 6 5 7 4 6 46 26 57 199 734 361 115 1,882 3,250 237 491 2 1 1 1 2 2 9 65 28 HOIAllaS FLYIVaH Dnaad Class of beneficiary relief TABLE 7.-Number of days in hospital for patients discharged during fiscal year 1926 from United States marine hospitals and other stations, by broad groups of conditions and class of beneficiary Total Abnormalities and congenital malformations Blood and blood-forming organs, diseases and injuries of Bones and cartilages, diseases and injuries of Circulatory system, diseases and injuries of Communicable and infectious diseases, not including tuberculosis and venereal _ Dental Digestive system, diseases and injuries of.. Ear, nose, and throat, diseases and injuries of Endocrines, diseases and injuries of Eye and annexe, diseases and injuries of__ Genito-urinary system,diseases and injuries of (exclusive of venereal) Hernia Joints and burst% diseases and injuries of_ Leprosy Lymphatic system, diseases and injuries of Muscles, fascim, tendons, and tendon sheaths, diseases and injuries of Nervous system, diseases and injuries of Obstetrics and gynecological conditions_ _ Parasitic diseases Poisonings and intoxications Psychiatric diseases Respiratory system, diseases and injuries of (exclusive of tuberculosis) 681 501 3,559 2,221 81,410 64,639 31, 121 3,004 58,396 36,362 7,706 10, 138 53,005 48,979 21,252 1,819 39,678 19,443 4,939 6,767 Mississippi River Cornmission 14 74 50 1,826 244 1, 287 36 911 342 129 37 3, 190 3 33 2, 559 3,966 602 6,528 48 16 2 75 6,926 . 18 510 12 434 252 449 27 555 218 350 1 33 191 6 19 1,229 7 863 16,459 4, 101 31 168 756 8,034 576 9 763 100 21 274 196 46 113 1,354 229 6,864 94 2 92 583 33 791 5 834 129 664 368 211 77 181 7, 183 1,906 1, 115 52 688 15 9 88 5 746 114 26 26 835 1,085 584 152 371 344 47 64 57 153 5,822 2,746 2,530 3,241 7,526 147 930 269 209 165 470 74 5 31 3,162 716 5 67 3 184 400 275 7,623 29 3,505 237 16,640 49 587 4,222 1,600 1, 115 204 1,734 1, 148 1, 221 16 65 8 166 62 142 658 232 20 33 99 61 234 524 2,953 1,247 15 5 23 368 289 159 28 24 271 203 843 7 1 33 50 22 2 - 402 1,057 3 83 323 678 2,480 34 53 972 206 27,326 25,801 32, 286 49 179 378 308 11,844 10,030 18,685 53,854 332 6,085 4,261 27,713 11,121 42,195 259 1,909 3,106 9,096 38,187 27,511 768 92 15 1, 272 1,722 2,465 33,753 38,904 46,675 36,912 U.S. Public U. S. Health Immi- Service ,„_. Miscelgration Officers '''''"'"'" laneous Service and Employees 16 461 42 439 3 595 1 24 2 12 2 1 127 57 41 71 33 244 34 593 83 , 36,863 apinuas H.rIvaH Group U. S. Amen- Foreign U.S. u s Navy Coast A ' ,and can seamen seamen Guard r''''''''' Marine Corps • Seamen, U. S. U.S. EmU. S. EngiU. S. Coast ployees U. S. neer Com- Veterand Corps LightGeo- pensa- ans' house and tion Bureau Army Service detic Survey ComTransmission port Service 01-1Eithl Class of beneficiary 27 17 1 cyl cgt TABLE 7.-Number of days in hospital for patients discharged during fiscal year 106 from United States marine hospitals and other relief stations, by broad groups of conditions and class of beneficiary-Continued Group Total Skin and its appendages, diseases and injuries of Tuberculosis Tumors Venereal diseases Inoculations Under observations Miscellaneous Total NOTE.-This table Seamen, U. S. U. S. Missis- Engineer AmeriU.S. sippi Navy Foreign U. S. Corps can Coast and River and seamen seamen Guard Army Marine ComCorps mission Atmy Transport Service 21, 334 149, 126 13,655 218,996 147 5,666 113,020 16,131 118,406 11,675 175,370 1, 136, 165 2, 132 74, 541 277 310 146 5,167 70 85 2,452 1,967 3,447 508 15,545 68 884 7,382 787,548 16,502 68,315 71 10 U. S. U. S. Coast and Lighthouse GeoService detic Survey U. S. U. S. EmPublic ployees U. S. U. S. Health Corn- Veter- Inami- Service Miscelpensagration officers Lepers laneous tion Bureau Service and Comemmission ployees 25 118 1,029 76 352 457 3,556 130 4,498 220 208 63 1,155 374 16 546 335 674 50 71 1,419 17,801 773 10,898 5 60 53 5,261 2 139 28 305 19 2,455 64 867 39 173 200 14,184 2, 160 9, 242 19 462 74 3,184 130 62 9 34 629 170 820 4,998 23,716 9, 218 2, 268 47,875 120,698 6,605 9,853 does not include immigration patients from U. S. Marine Hospital No. 43, Ellis Island, N. Y. 260 67 35 46 2 187 36,863 716 HDIAllaS FIYIVaH OFIgfla Class of beneficiary 257 PUBLIC HEALTH SERVICE Grand total c/2 98,811 45,753 51,757 24,625 8,333 4,886 213 1,597 S ti 6 4 k •°, 41 P. Total 7... Inoculations and vaccinations 0 . Genito urinary Tuberculosis Neuropsychopathic Eye, ear, nose, and throat 59,391 45,198 25,756 44 66,194 14,024 12, 573 252 15,865 6,106 3,474 41 533 26 56 5,950 „ Marine hospitals Relief stations Coast Guard vessels Contract physicians Dental Station General medical States TABLE 8.—Classification of out-patient treatments furnished at United marble h,ospitals and other relief stations, fiscal year 1926 6,814 1,933 30,812 314,879 22,091 1,395 10, 148 203,258 5 43,300 38 4,523 13 10,702 2,292 147,400 65,384 42,336 363 617 160,498 75,477 35,720 3,366 40,978 572,139 DIVISION OF VENEREAL DISEASES In charge of Asst. Surg. Gen. MARE J. WHITE It is now eight years since the Division of Venereal Diseases was established as a part of the Public Health Service. While the act creating the division is specific, in that it deals exclusively with venereal diseases, it is, nevertheless, in definite harmony with prior legislation relating to the scope and purposes of Federal health activities. The Federal policy of cooperating with the State health departments was included in the act of 1893, and the authority to study and investigate diseases of man and conditions influencing the propagation and spread thereof was provided by an act in 1912. The same authorizations and policies were combined in the act which created the Division of Venereal Diseases. The importance of venereal disease control was such as to necessitate the establishment of a special division to carry on the work, which is universally recognized as an essential and productive activity of the greatest value. The Work of the division has developed mainly along the line of cooperative work with the State boards of health for the prevention and control of venereal diseases within the States. There has been built up a unified program of control activities throughout the country. Every State has enacted practically uniform laws or regulations having the force of law as a basis for a control program. Clinics have been established in all parts of the country, in which standard methods of diagnosis and treatment are employed, where indigent patients can receive modern scientific treatment without charge or for a nominal fee. Pamphlets, motion picture films, slides, and exhibits are prepared by the division and furnished to the board of health of each State for educational work. Standards have been established in the field of sex education. The reduction of the appropriation under which the division is operating is a serious drawback to the continuance of the program. For the fiscal year 1926 only $75,000 was appropriated for the maintenance of the division— $74,000 less than the amount for the previous year. There was no allowance made for allotments to States carrying on cooperative control activities. For the fiscal year 1927 the division will again have only $75,000 for maintenance and expenses. It would seem that sufficient funds to support this activity, so essential to the public heOth, should be forthcoming. COOPERATIVE WORK WITH STATE HEALTH DEPARTMENTS The extent as well as the nature of the cooperation with State health departments varies. At the present time there is in each 258 PUBLIC HEALTH SERVICE 259 State, upon the State health officer's request and recommendation, a Federal appointee who acts as the venereal disease cooperating representative of the service. As a Government official he is also authorized to use the free mailing privilege for the official correspondence and literature required in the cooperative work. He is at the same time the venereal disease control officer of the State health department. In addition to this cooperation, it is practicable for the service to detail other representatives for the following kinds of work: 1. To promote community interest by conferences with local authorities industrial and civic organizations, editors, other publicspirited citizens, nurses, midwives, social and probation workers, for the purpose of ameliorating conditions that facilitate the spread of venereal diseases. 2. To feature, from the viewpoint of venereal disease prevention, the importance of sex hygiene and the necessity of supervision of infected persons who are disinclined to continue treatment until cured. 3. To deliver venereal disease lectures to selected groups, such as industrial, commercial, and domestic employees, and to physicians who seek a fuller understanding of the venereal disease problem. Requests received from schools, colleges, associations, or other groups for the detail of service lecturers or for other assistance to them in carrying on their own plans for promoting public interest in venereal disease work are referred to the State department of health having jurisdiction. If that department requests the Public Health Service to cooperate, assistance is given wherever practicable. This is one of the most important steps for the reason that it brings to the attention of residents of a State the fact that the control of venereal diseases within the State is the legal and exclusive function of their own State, county, and municipal health departments. The cooperative work with the States affords concurrent opportunities for the practical study and investigation of the various conditions encountered, and the results are utilized by the division in improving its educational facilities. In Kentucky the State health department's venereal disease program includes the appointing of individual physicians in the less densely populated sections for the treatment of indigent venereal disease patients and in promoting venereal disease prophylaxis throughout the State. These special features have been made the subject of studies and investigations by a service representative who was detailed for cooperative work with the State department of health, and it is believed that out of this study will come improvements in the measures for venereal disease control. In the State of Indiana a special effort has been made to interest the probation and other custodial agencies in giving information concerning venereal diseases to delinquents in their charge and in having them examined for the detection and relief of disease. The studies and investigations in connection with this work include the use of the "Keeping Fit" and "Youth and Life" exhibits and of service publications with a view to determining to what extent they are useful in giving instruction to delinquents. Necessary revisions will be made as a result of these studies. For use in connection with this work the service prepared a special publication known as "Venereal Disease Manual for Social and Corrective Agencies," for which 14656-26-18 PUBLIC HEALTH SERVICE 260 there is considerable demand. In addition to the limited number officially distributed, over 1,800 copies have been purchased by individuals from the Superintendent of Documents. It is realized that the social and corrective agencies come in contact with groups that are potent factors in the dissemination of venereal diseases, and the studies and investigations in this connection are for the purpose of more effectively controlling both the actual and potential sources of infection among the delinquent groups. Plans for a state-wide keeping-fit campaign in Indiana have also been undertaken. This campaign is similar to that carried on in the State of Mississippi last year. In Georgia the work has consisted largely of lectures to women's organizations, working men and women, botli white and colored, and special lectures to colored midwives. In the State of Tennessee similar work was begun. CLINICAL STUDIES AND INVESTIGATIONS The work at the Hot Springs venereal disease clinic for indigents has been continued. Clinical studies and investigations are made, and all patients treated there are given special instruction in the necessity for the early detection of the diseases and their prompt and adequate treatment. Such patients are also instructed in the regulations controlling the interstate travel of infected persons. During the year 3,570 patients were examined. Of this number 2,211 were syphilitic, 857 had gonorrhea, and 11 chancroid. Total number of visits to the clinic for examination, treatment, or advice amounted to 68,251—an increase of 2,938 over 1925. Diagnosis Wassermann tests + — Total Spinal punctures 1,799 1,399 3,191 4,061 4,990 5,460 351 189 870 470 Year 1925 1926 Increase Decrease 400 Dark field examinations + 168 Total — 53 106 18 70 71 176 53 52 105 Treatment Year 1925 1926 Increase Decrease Arsphen- Mercury amin 12,713 12,419 294 18,580 19,896 1,316 Spinal treatments 285 275 10 Gonorrhea Chancroid Total 19,315 22,275 60 186 50,953 55,051 2,960 126 4,098 Various studies have been conducted during the year. A series of cases was treated with flumerin in response to a special request. A report of the results has been completed. Cardiographs of aortitis and aneurysm were made at the clinic for the preparation of strip PUBLIC HEALTH SERVICE 261 film views. At the present time a comparative study of the Kahn precipitation test, comparing it with the routine Wassermann technic, is under way. Proposed studies for the coming year are the treatment of late syphilis with malaria and experimental work with a view to determining the effect of tetra-ethyl lead on the spirochete. The officer in charge of the division's venereal disease clinic at Hot Springs was detailed to deliver a course of lectures at the venereal disease institute of the Florida State Board of Health, which was attended by physicians of the State desirous of becoming more proficient in venereal disease work. During the year the division prepared strip film views of syphilis and of skin diseases simulating syphilis, which were distributed to State health departments for use in their venereal disease work. These strip films were made from photographs obtained from a number of prominent syphilologists and dermatologists who were interested in promoting the control of venereal diseases and in stimulating the general practitioners to fortify themselves for the detection of the disease. The following is a list of the strip films: Primary syphilis. Congenital syphilis. Early syphilis (parts 1 and 2). Late syphilis (parts 1 and 2). Lesions of syphilis. Treponema pallidum. Lesions simulating syphilis. Chancres. Cutaneous syphilis. Cutaneous syphilis in negro. Cardiographs of aortitis and aneurysm. Four hundred and five sets of films were lent to State boards of health. The Kentucky plan of appointing cooperative clinicians has been reported elsewhere. SOCIAL STUDIES AND INVESTIGATIONS "Venereal Disease Manual for Social and Corrective Agencies" was prepared as a result of studies and investigations made the previous year into the necessity for venereal disease control work among delinquent groups. The manual contains suggestions and other informative material emphasizing the following items: 1. The prompt detection and treatment of venereal diseases among persons coming under the actual and prospective observation, supervision, or control of juvenile, and other corrective agencies. 2. The clinical and social management of these cases, not only in the interest of personal health but as a protection to the public, and as an assurance against the infected individual becoming a public charge later as a result of inadequate treatment. 3. The prevention of venereal diseases among this group through proper instruction and social guidance. This manual is especially designed for the use of court and probation officers, social workers, nurses, visiting teachers, policemen and policewomen, jailers and wardens, and superintendents and matrons of homes for dependent, delinquent, and defective classes. 262 PUBLIC HEALTH SERVICE Special work was undertaken with large industrial concerns, railroads, steamship companies, and large manufacturing plants in a number of the States for the purpose of interesting the management in promoting instruction for the prevention and relief of venereal diseases among their employees. Most of the concerns welcomed this work and purchased literature, placards, etc., for the use of their employees. PUBLICATIONS The "Venereal Disease Manual for Social and Corrective Agencies" (V. D. B. 81), mentioned above, is not available for free distribution. Because of the cost of printing and binding it is sold by the Superintendent of Documents, Government Printing Office, at 50 cents per copy. In addition the division prepared and issued a folder (V. D. B. 80), entitled "Health Maintenance Relief and Prevention of Venereal Diseases." This was the first of a health maintenance series to set forth the principal conditions which venereal diseases could cause, but which frequently are known under names that do not suggest their cause. Another publication, the placard "The Venereal Diseases" (V. D. B. 73B), is a revision of an earlier placard. It is designed for the information of the masses, and has been widely distributed and posted in lavatories of trains and railroads, large industrial plants, etc. The publication, "Venereal Disease Information," during the past year has proved to be very popular, the Superintendent of Documents having received approximately 10,000 paid subscriptions, of which 150 are purchased by the British Social Hygiene Council for distribution to their branch offices throughout the British Empire. The other publication, "Social Pathology," which deals with the socio-economic aspects, although mimeographed and issued irregularly, has nevertheless created a growing demand. Eight thousand copies have been distributed. It is unfortunate that this information can not be furnished the public in printed form. If printed, there is no doubt that a large subscription list would be gotten, which would more than pay for the cost of its production and would certainly meet a very important demand. EDUCATION WORK WITH NEWSPAPERS AND JOURNALS The educational campaign carried on by means of newspapers and journals which was instituted during 1925 was carried forward successfully this year. It was found that certain journals readily took part in the movement to disseminate information concerning syphilis and gonorrhea. From all parts of the country came assurances of support. The number of articles published bears evidence to the value placed Upon the effort. Twenty-five special articles were prepared for distribution. The wide range of subjects is of interest: "Maine legislates against spread of venereal diseases," "Marriage and social diseases," "Massachusetts law permits change in venereal disease reporting," "Care of mothers urged," "Preventable deafness," "Overcrowding facilitates spread of social diseases," "Syphilis and heart disease," etc. PUBLIC HEALTH SERVICE 263 In addition to the labor papers and certain newspapers which cooperated so heartily the first year, articles have been accepted for publication by medical journals, women's journals, and agricultural journals. WORK WITH THE COLORED POPULATION Special work with the negro population was carried on this year in Georgia and Tennessee. During the five months the representative of the Division of Venereal Diseases was on this detail 130 meetings were held, with a total attendance of 18,199 persons. Films were shown in connection with 72 of these lectures. In all 4,800 pamphlets were distributed. The special representative of the division was detailed to work in these States in cooperation with the State boards of health. The program outlined included the effecting of contacts with industrial workers, physicians, Muses, midwives, ministers, colleges, and fraternal groups. Physicians were shown the strip films and methods of treatment were demonstrated. After five months of intensive work in these two States the division's representative feels that the work is particularly worth while. Physicians have promised to give better cooperation and make full reports of cases of venereal diseases; teachers are ready to give more attention to sex hygiene and venereal disease instruction; and among; the mass of the population there is better understanding of the significance of the campaign and need for treatment, due in large measure to public health activities. Aside from the special work among the negroes, the regional consultant, who was on an educational detail in Georgia, talked to many negro women, nurses, midwives, attendants at insane hospitals, and to girls. The educational facilities prepared by the service for use among the colored population continued in demand. Specially prepared exhibits have been adapted from the service exhibits. "Youth and Life," for colored girls and young women, and "Keeping Fit," for boys and young men, were used. The articles prepared for the newspapers have been mentioned in another section of this report. The negro papers were particularly willing to use the articles to distribute this information among their readers, an activity which, it is believed, is of great value, though the exact extent of the good can not be measured. PAMPHLETS, FILM SHOWINGS, LECTURES, EXHIBITS The Public Health Service has received 12,235 requests for pamphlets. State boards of health have received from the public 28,891 similar requests, a total of 41,126 requests. Table 1 indicates the number of pamphlets purchased by States. State boards of health borrowed or purchased 95 exhibits, 2 lantern slide sets, and 35 motion picture films. Table 2 lists these purchases by States. The American Social Hygiene Association reports the sale of 402 exhibits, 8 sets of slides, and 30,458 pamphlets to State boards of health and others. PUBLIC HEALTH SERVICE Lectures reported by State boards of health total 4,133, with an average attendance of 109. Exhibit material was used at 391 of these lectures. Total lectures for the year numbered 4,267. Four hundred and four film showings, average attendance 202, and 778 exhibit and slide showings, with an average attendance of 252, are reported. A statistical report of the educational activities of the State boards of health is shown in Table 3. OASES OF VERMALDISFIASNIS REPORTED TO STATE BOARDS OF RRALTH Disease ard Number OhAlne'roid 1919 1920 1921 1922 1923 1924 1925 1926 1919 1920 1921 1922 1923 1924 1925 1926 7,843 10,861 72313,226 8,935 7,777 8,484 6,742 7,029 Syphilis if* 100,466 142,869 184,090 171,824 172,258 194,936 201,692 215,547 Gonorrhea 1919 1920 1921 1922 1923 1924 1925 1926 131,193 172,387 189,927 152,959 156,826 161,676 166,208 166,655 REPORTING OF VENEREAL DISEASES Cases of venereal diseases reported to State boards of health from till sources amounted to 389,231. The full report is found in Table 4. This total is an increase of 3.89 per cent over last year.' The accompanying diagram illustrates the progress made in venereal disease reporting from 1919 to 1926. The figure given in the 1925 annual report was 372,813. since publication has changed that figure to 374,642. Additional data received PUBLIC HEALTH SERVICE 265 Since there are reports from fewer clinics this year, the increase in the number of cases reported to State boards of health must be attributed to a more active interest in reporting venereal diseases on the part of physicians. Table 5 shows the States ranked according to the percentage of increase or decrease in the number of cases reported to State boards of health. Thirty-seven States are listed. Incomplete return or change of method of reporting account for the omission of several, while other States have made no reports for 1926. The accompanying graphs indicate the monthly variation in the cases of gonorrhea and syphilis reported in 1925-26. CASES OF SYPHILIS AND GONORRHEA REPORTED TO STATE BOARDS OF HEALTH, BY MONTHS DURING FISCAL YEAR 1926 19,000 -- 1111111r Syphilis - 18,000 -- - 17,000 __ 16,000— 15000_ 14,000_ 13,000 __ 12,000 __ 11,000 A I' / % 1 / 1 / 1 d, 1 Gonorrhea \ • • •--\ /'•• \ / v.„,......\ \--,/ • • • - I I I Iii t LiJ I- I Y1 g VA A CLINICS State boards of health report activities of 416 clinics. Last year reports were received from 495. Sixteen of the clinics from which no reports were received this year were reported discontinued, some for lack of funds. But the majority are accounted for by the fact 266 PUBLIC HEALTH SERVICE that the State boards of health of a number of States have discontinued sending clinic reports altogether. Admissions to these 416 clinics totaled 100,776. In this number there are included 58,297 cases of syphilis, 39,636 of gonorrhea, and 2,843 of chancroid. The average number of admissions per clinic was 242. The number of patients discharged as noninfectious was 44,329, an average of 106 per clinic. The graph indicates the yearly averages of admissions and discharges from clinics for the eight years 1919-1926. (See opposite page.) SYPHILIS AND GONORRHEA - TOTAL CASES REPORTED TO SPA], BOARDS OF NM AT,TH, BY MONTHS AND YEARS 36,000— - 35,000_ _ 1926 34,000_ _ 33,000— i• \A 32,000— 31,000-30,000_ 29,000— 28,000 i t / % / 0 / 1 / 1 i /I ...4i 1925 % / ‘ ti , " 1 1t// V 4fai 4: I- l; 0 4 4 / / i - _ 4 In diagnosing these cases 291,803 Wassermann tests and 188,674 microscopic examinations for gonococcus were made. The total treatments given were 1,881,380. This number includes 482,403 doses of arsphenamin administered. A complete report of clinics is contained in Table 6. States ranked according to the monthly and daily average of admissions to clinics are shown in Table 7. State boards of health report 651,785 doses of arsphenamin or similar product administered from July 1, 1925, to June 30, 1926. The reports by States are found in Table 8. PUBLIC HEALTH SERVICE 267 CORRECTIONAL AND PENAL INSTITUTIONS Reports were received by the division from 33 correctional and penal institutions during the year. There were admitted to treatment 7,713, of whom 3,517 were suffering from syphilis, 4,063 gonorrhea, and 133 chancroid. Table 9 gives the numbers of treatments given, Wassermann tests made, etc. PATIENTS ADMITTED TO CLINICS Average per Clinic Year 1919 1920 1921 1922 1923 1924 1925 1926 50 100 150 200 250 300 350 400 354 329 318 261 -.!•• , • r 232 234 223 242 PATIENTS DISCHARGED AS NONINFECTIOUS Average per Clinic Year 20 40 60 80 100 1919 1920 1921 1922 1923 1924 1925 1926 120 125 111 108 102 97 107 STATE LAWS AND REGULATIONS STATE LEGISLATION The only report of a change in legislation comes from Ohio. The Ohio Sanitary Code was amended to permit physicians to report cases of venereal diseases by initials or case number in lieu of reporting by name of patient. In case reports are made by initials or number an office record must be kept whereby cases may be readily identified. This change was made on the recommendation of the medical profession. 268 PUBLIC HEALTH SERVICE In the past year an effort was made to evaluate the legal measures which have been in force touching on the control of the venereal diseases. A letter was sent to each State health officer asking for the venereal disease control laws and regulations of that State. In addition, the opinion of the health officer was sought in the matter of the value and effectiveness of these measures. The answers which were received from 35 health officers indicate that on the whole the legal measures are considered adequate. There are, however, striking exceptions to this general opinion. Nearly all of the reports agree that lack of funds hampers the proper administration of the laws. Thirteen- health officers mention particularly the difficulty of securing proper reporting of venereal diseases. All agree that the carrying out of this regulation can not be forced; that in the last analysis the intention of the physician will determine whether or not complete reporting can be attained. The cooperation of the physician is, of course, a most necessary factor in the campaign of disease control. It is brought out by several that on the willingness of the whole—members of the medical profession, the legal profession, State administrative officers, and the lay public—rests the effective control of venereal diseases, and that education is more essential than further enactments of law. COURT DECISIONS During the year two decisions of interest were handed down. The Kansas Supreme Court decided that when venereally infected women and girls were sent from a county to the State quarantine hospital for women pursuant to orders of isolation duly issued by the health authority, the county was liable for the expenses of the women in returning to their homes upon discharge from the hospital. In the California First District Court of Appeals was heard the ease of a woman ordered quarantined by the health officer of San Francisco because she was found to be suffering from gonococcus infection. The woman sought her release, claiming that such power resided alone in the State board of health. The court denied her claim. A statistical summary of all activities for the fiscal years 1925 and 1926 is arranged in Table 10, page 280. TABLE 1.—Educational pamphlets and placards purchased and reprinted by State boards of health, July 1, 1925, to June 30, 1926 State United States Alabama Arizona 1 Arkansas California Colorado Connecticut Delaware District of Columbia 1 Florida Georgia Idaho Illinois Indiana Iowa 1 Kansas 1 Not reporting. Total A 731,044 100, 500 B 30,000 38,000 4,000 D E 55,944 182, 400 149,900 146,400 21.000 2 C 20,000 10,000 5,000 10,000 F Others 16,500 79,400 1,000 10,000 11,000 10,000 12,000 2,000 4,000 2,000 60,000 10,000 10.000 1.000 5. 000 1.000 3 000 2 Exclusive of 40,000 leaflets "Instructions to patients." 10,000 10,000 5,000 15,000 10,000 Placards 269 PUBLIC HEALTH SERVICE TABLE 1.-Educational pamphlets and placards purchased and reprinted by State boards of health, June I, 1925, to July 30, 1926-Continued State Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada I New Hampshire New Jersey 4 New Mexico New York North Carolina I North Dakota Ohio Oklahoma 1 Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah' Vermont Virginia Washington West Virginia Wisconsin Wyoming A Total C B 2,000 2,000 4,000 900 6, 544 6,000 130,000 15,000 38,000 2,000 19, 500 5, 000 2,000 20,000 10,000 20,000 10,000 15,000 30,000 30,000 13,000 10,000 2,000 500 10,000 400 800 400 400 500 20,000 50,600 6, 500 2,000 14,000 2,000 5,000 2,000 10,000 10,000 30,000 900 544 2,000 3 40,000 Placards Others F E D 15,000 7, 500 2, 500 25,000 11,000 500 76,600 61, 500 2,000 13,000 65,000 5,000 13,000 24,000 13,000 77, 500 10,000 25,000 15, 500 16,000 10.000 15, 500 20,000 1,000 5, 500 4 For 11 months only. 3 Exclusive of 5,000 score cards. B, the general the above table the letters A to F stand for the following groups: A, men; public; C, boys; D, parents; E, girls; F, educators. 1 Not reporting. .NOTE.-In borrowed or TABLE 2.-Eachibits, lantern-slide sets, and motion-picture films 1926 purchased by State boards of health, July 1, 1925, to June 30, State Exhibits Slides Films 95 2 35 United States Alabama Arizona 1 ., Arkansas California Colorado. Connecticut Delaware District of Columbia 1 Florida Georgia Idaho Illinois Indiana Iowa' Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri 'Not reporting. 4 1 _ 25 3 State -.ts hEx-ibi Montana Nebraska Nevada' New Hampshire New Jersey New Mexico New York North Carolina 1 North Dakota Ohio Oklahoma' Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah 1 Vermont Virginia Washington West Virginia Wisconsin Wyoming Slides 2 28 4 _ 15 11 2 Includes 1-strip film. 7 12 54 Films I Includes 4-strip films. 36 270 PUBLIC HEALTH SERVICE TABLE 3.—State report of educational activities, July 1, 1925, to June 30, 1926 Lectures State United States Alabama Arizona 1 Arkansas California Colorado Connecticut Delaware District of Columbia 1 Florida Georgia Idaho 2 Illinois Indiana Iowa 1 Kansas Kentucky Louisiana Maine Maryland Massachusetts 2 Michigan Minnesota Mississippi Missouri Montana 2 Nebraska Nevada' New Hampshire New Jersey 2 New Mexico New York North Carolina 1 North Dakota Ohio Oklahoma 1 Oregon 2 Pennsylvania fRhode Island South Carolina 4 South Dakota Tennessee Texas 2 Utah 1 Vermont' Virginia Washington West Virginia Wisconsin Wyoming Pamphlets distributed Film showings Num- Average Exhibit -,„,.„.„ Average -,,,,.„ Average attend- material '"“rn- attend- ''''''''. attendber ber ber ance used ance ance 969,592 4, 133 109 404 202 24, 551 247 99 5 300 19,057 25,911 4,047 4,524 66 11 2 7 1 170 40 50 37 100 1 101 83 244 3 178 42 82 19 75 151 22 5,118 21,521 3,612 3,827 10,111 16,579 50 1 137 8 59 125 110 96 104 83 17,509 10,803 2,604 3,422 144,780 64 16 12 5 13 67 677 249 226 81 398 31,872 2,836 170,301 22 327 75 111 4 737 122 80 5,009 1 50 1 351 14,763 65,807 823 476 90 150 286 31 31 10 125 323 22 11, 143 5, 505 412 55,318 49,430 12,568 33,472 185 48,218 1,167 105,262 36,774 1 Not reporting. 2 For 11 months only. For 6 months only. Exhibit and slide showings 391 1 2 8 2 60 215 6 17 135 149 252 434 103 9 75 6 333 22 2,960 9 278 1 300 2 50 2 38 6 46 2 216 145 475 2 14 215 92 1 125 2 75 208 2 14 175 123 1 156 12 48 106 63 22 1 2,481 167 19 101 61 14 4 116 10 139 273 94 28 50 209 232 979 157 50 159 40 30 189 145 4 778 For 3 months only. For 7 months only. 271 PUBLIC HEALTH SERVICE TABLE 4.-Cases of venereal disease reported to State boards of health, July 1, 1925, to June 30, 1926 State ... United States Alabama Arizona 1 Arkansas California Colorado Connecticut Delaware District of Columbia 1 Florida Georgia Idaho 2 Illinois Indiana Iowa 1 Kansas Kentucky Louisiana Maine Maryland Massachusetts 2 Michigan Minnesota Mississippi Missouri Montana a Nebraska Nevada 1 New Hampshire New Jersey 2 New Mexico New York North Carolina 1 North Dakota Ohio Oklahoma 1 Oregon 2 Pennsylvania Rhode Island South Carolina 2 South Dakota Tennessee Texas 2 Utah 1 Vermont 5 Virginia Washington West Virginia Wisconsin Wyoming 3 Not reporting. aFor 11 months only. 3 4 For 6 months only. For 3 months only. Chancroid Total Syphilis Gonorrhea 389,231 215,547 166,655 7,029 15,374 9,710 5,279 385 4,508 19,181 1,965 2, 229 691 2,918 10,629 507 1, 135 199 1,530 8, 137 1,420 1,079 398 60 415 38 15 94 5,947 11,006 378 30,985 4,208 3,719 5,719 $4 11,349 2,099 1,921 4,980 292 19,274 1,981 307 307 2 362 128 1,588 41,901 6,873 842 6,040 6,611 25,678 10,824 33,666 7,823 74 3,788 569 29, 332 3,475 245 3,194 1,883 13,963 5,150 13,221 3,936 21 1,195 1,010 12, 212 2,917 587 2,567 4,728 11,620 5,613 20,249 3,270 53 2,543 9 357 481 10 279 410 7,679 336 38,043 207 4,561 81 28,889 203 3,063 248 9,089 55 7 65 1, 146 10,812 296 5,851 849 4,596 1 365 1,683 5,228 1,032 4,816 835 24,029 32,419 444 2,592 438 1,917 122 16,614 18,806 1,235 2, 563 593 2,893 713 6,444 12, 755 4 73 1 6 427 2,439 1,932 10,477 3,293 10 179 1,682 764 7,061 787 4 248 706 1, 129 3,204 2,458 6 5 For 7 months only. 95 61 196 622 50 971 858 51 39 212 48 272 PUBLIC HEALTH SERVICE TABLE 5.-States ranked according to the percentage of increase or decrease in the number of cases of venereal disease reported to State boards of health, 1926 over 1925 STATES SHOWING INCREASE Rank 1 2 3 4 5 6 7 8 9 State Idaho (incomplete) West Virginia Texas (incomplete) Mississippi Delaware Alabama Nebraska Washington North Dakota Per cent Rank 1 47.08 27. 36 1 26. 34 24.62 21.02 19.43 14.61 13. 71 13. 35 10 11 12 13 14 15 16 17 State Per cent South Dakota Minnesota Maryland Ohio New Jersey (incomplete) Michigan Pennsylvania New York 8. 16 6.65 6. 64 6. 18 1 5. 32 3. 37 2.91 .26 STATES SHOWING DECREASE 18 19 20 21 22 23 24 25 26 27 Illinois California New Hampshire Georgia Kentucky Wisconsin Rhode Island Arkansas Louisiana 1VIissouri 0.86 1. 23 4.21 5. 08 5. 30 5. 40 5. 49 6. 97 7.37 9. 20 28 29 30 31 32 33 34 35 36 37 Colorado Indiana Connecticut Oregon (incomplete) Florida Kansas New Mexico Maine Virginia Massachusetts (incomplete) 10. 11 11.28 11.86 1 12. 53 15. 35 17. 08 24. 49 25.94 27. 17 1 37. 52 1 Figures for 1926 are for 11 months only. NOTE.-Owing to incomplete returns from Montana, South Carolina, Vermont, and Wyoming, and a change in the method of reporting in Tennessee, the figures for these States are not comparable and have been omitted from the above table. Arizona,Iowa, North Carolina, Oklahoma,and Utah did not report for 1926 and also have been omitted. United States Alabama Cooperative Albany Anniston Bessemer Birmingham (2) Gadsden Huntsville Mobile Montgomery Riderwood Selma Talladega Tuscaloosa Arkansas Fort Smith Hot Springs (2) Little Rock North Little Rock. Pine Bluff Texarkana 8 171 . 'i Microscopic examinations, gonococcus 0 Doses of arsphenamin administered g rcs 72 Treatments given 74 ;L.43 .. 44 a P., cn Patients discharged as noninfectious Patients admitted Gonorrhea State and city Total monthly reports received TABLE 6.-Report of clinics reporting to State boards of health, July 1, 1925, to June 30, 1926 4,410 100, 776 58,297 39,636 2,843 44,329 1,881,380 482,403 291,803 188,671 168 10,697 7, 770 2,678 249 6,269 127,222 47, 396 16,637 2, 596 12 12 12 12 24 12 12 12 12 12 12 12 12 3,251 455 116 300 3, 542 80 167 1,461 474 59 169 158 465 1,879 402 109 263 2,875 39 63 1,180 356 44 159 73 328 1,230 46 7 37 665 37 97 262 87 14 10 82 104 142 7 2, 112 424 49 315 1,732 84 298 779 7 57 43 369 10, 939 2, 596 830 1,189 14,812 452 1,573 9,072 1,752 355 1, 108 986 1,732 3, 560 1, 591 287 149 6,548 130 801 1,521 335 41 455 629 590 661 118 17 64 795 50 576 103 3 33 28,964 3,897 1,888 4,372 39,549 2,227 6,036 23,437 6,212 469 3, 132 2,025 5,014 81 3, 746 2,655 1,044 47 3, 238 64,518 15, 768 9,962 3,487 12 22 12 12 11 12 50 2, 727 684 9 47 229 50 1,968 524 8 45 60 15 3,002 I 2 15 203 534 57, 773 4,879 247 554 531 534 12, 550 1,839 157 383 305 84 5,622 3,681 45 126 404 2, 525 698 22 20 222 746 159 1 2 136 2 4 7 19 31 1 13 1 33 5 75 132 273 PUBLIC HEALTH SERVICE California Fresno Los Angeles (3) Oakland San Diego San Francisco (4)_ San Jose Stockton Colorado Springs Denver (2) Fort Collins Pueblo Connecticut Bridgeport Hartford New Haven New London Stamford Waterbury Delaware Doiier Wilmington (2) Florida Georgia Atlanta Augusta Brunswick Columbus Macon Savannah Illinois - Microscopic examinations, gonococcus tests Wassermann made Doses of arsphenamin administered Treatments given Patients discharged as noninfectious Chancroid Gonorrhea 6, 327 3,839 2,446 42 1, 119 117,779 48,645 22,680 5,047 6 36 12 11 47 12 12 17 59 80 2,816 1,605 1, 191 364 428 792 124 162 291 508 1,767 1,247 30 44 13 229 308 537 4 20 87 311 34 247 189 9 242 1,341 346 733 40,525 15,333, 6, 183 11,781 3,639 3,328 5,350 4,375 1:000 50,571 22,117 10666 2731 229 509 928 8,0021 2, 175 151 2,239 588 414 1,325 22 308 16 528 18,500 2,472 1,351 1,884 1 645 11,544 3,348 2,963 118 1,666 147 541 80 944 46 281 50 1, 545 176 113 5 12 1 632 252 364 12 24 12 12 26 418 78 110 12 195 6 39 14 222 72 56 15 16 374 88 50 72 884 381 482 21 487 18,434 5,085 1,807 2,083 12 12 12 12 12 12 137 320 148 22 213 44 84 116 70 13 76 22 53 199 78 9 121 22 34 154 64 14 207 14 4,079 5,649 6,181 625 1,109 791 1,005 1,616 1,661 124 364 315 321 309 658 61 412 46 91 641 153 33 1,137 28 32 266 166 80 20 108 2,966 1,475 359 150 12 20 93 173 25 141 52 28 16 4 92 16 1,532 1,434 530 945 113 246 126 24 66 1,678 950 568 160 548 12,620 5,882 3,377 981 10 178 102 943 2,945 33 40 1,631 2 104 39 783 817 3 3 1,626 5 71 7 5 16 4 27 19 198 283 4 44 371 11 25 15 9 9 327 124 44 146 18 15 207 72 3, 106 2,482 576 48 458 12 12 12 12 12 12 1,014 223 49 427 760 633 11 9 25 31 6 178 246 1 8 5 11 11 12 6 12 Alton Arcadia Fort Pierce Jacksonville Miami Ocala Perry Tampa Syphilis 136 60 Colorado Alton Cairo Carlinville Chicago (9) Decatur East St. Louis. Herrin Litchfield Moline Peoria Princeton Robinson _ Rockford Springfield West Hammond Patients admitted Total State and city Total monthly reports received TABLE 6.-Report of clinics reporting to State boards of health, July 1, 1924, to June 30, /926-Continued 15 61 43 198 734 4 106 517 258 47 967 126 86 3 46 150 277 219 510 31 596 8, 725 3,631 4,919 12 12 9 107 12 12 12 12 5 12 12 5 12 12 12 79 90 171 31 95 126 35 35 75 7,058 2, 769 4, 152 68 96 164 153 129 311 31 52 84 24 14 38 19 12 31 86 120 206 3 1 4 5 5 37 20 57 186 186 373 10 12 22 54 23 166 83 175 2,978 121 134 108 5 137 1, 732 7 185 29 87 I 4 30 178 2 1 6' 41 325 20 22 607 342 1,093 4,649 37 514 5,356 37,507 13,619 12, 500 10, 274 4,549 7, 725 13,922 1,224 1,667 181 192 404 217 863 1,712 974 6,249 2,288 4,946 4,503 1,736 100 3 795 705 33 389 31 223 29 317,084 45,451 28,468 44,406 149 172 591 3,891 219 6 1,982 1,162 330 • 433 202 638 281,025 33,075 25,796 40,824 601 240 3,861 1,318 637 235 488 5,720 57 137 781 899 272 44 211 2,280 31 57 521 842 629 510 887 3, 183 7 1 43 19 12 150 112 120 486 1,605 629 585 7,573 5,269 22 448 3,392 274 PUBLIC HEALTH SERVICE Junction City Kansas City (2) Topeka Wichita (2) Kentucky Ashland Covington Frankfort Fulton and Hickman Georgetown Henderson Lexington Louisville Maysville Mount Sterling Newport Owensboro Paducah Paintsville Somerset Winchester Louisiana Monroe New Orleans Shreveport Maine Bath Calais Portland (2) Maryland 1,574 4— -4 Kansas 12 12 12 12 12 12 24 12 12 12 12 12 12 12 12 117 28 42 645 194 169 709 108 55 47 235 24 35 273 474 34 15 17 314 94 98 340 56 17 26 112 17 32 160 242 83 13 25 319 97 58 332 52 33 21 89 7 3 112 230 60 476 259 12 12 12 24 16 96 133 231 68 65 126 107 877 101,520 19,816 Microscopic examinations, gonococcus 158 20 30 354 345 12 533 45 216 4, 144 2,451 21 328 377 10,568 2, 738 1,631 937 808 3,584 6,176 218 1, 151 1,360 93 722 816 58 20 376 483 45, 175 13, 113 6,809 1,985 2, 286 428 1,114 389 223 221 2,624 3,883 285 27 445 371 252 171 81 313 312 201 1,352 83 116 48 2,891 1, 217 156 5 237 117 60 47 27 140 547 835 73 91 30 10 3 4, 193 3, 133 4,165 452 637 500 9,007 15,964 946 43 2,518 555 318 321 170 1,353 1 2 215 2 234 16 28 66 105 2 27 34 173 5 tests 2,453 185 40 37 1,013 284 325 2,422 106 25 51 396 69 121 916 1,131 5,276 1,007 1,449 15,356 2, 315 7, 255 40,395 1,475 1, 176 1,748 2,842 960 1,230 8,698 10,347 34 Wassermann made 7, 121 51 7 13 181 88 92 22 13 39 11 199 5 1 66 89 12 3 13 37 Doses of arsphenamin administered Treatments giuen Patients discharged sa noninfectious Chaneroid 4 04 C., rD .,_9. Indiana. Anderson Columbus Elwood Evansville Fort Wayne Hammond Indianapolis (2) Kokomo Madison Marion Muncie Newcastle Richmond South Bend Terre Haute = Gonorrhea Patients admitted Total State and city Total monthly report received TABLE 6.-Report of clinics reporting to State boards of health, July 1, 1925, to June 30, /926-Continued 229 2,773 516 156 188 4,316 650 1,150 1,760 1,045 157 1,513 1,554 1 229 152 5,035 2,646 2,160 11 12, 12] 9, 12 71 12, 12 81 41 10, 8 9 10 5; 11 114 169 55 189 107 82 1,174 614 560 47 37 10 54 32 17 19 19 757 516 231 2,229 1,020 1,008 40 29 70 4 2 2 123 42 69 40 34 6 53 43 10 41 24 17 5 4 1 61 34 27 26 2,042 1, 121 886 35 1,871 18,485 8,312 4,085 3,015 21 12, 12, 115 463 1,464 100 184 837 15 264 607 30 46 15 20 1,795 965 9,932 7,588 755 4,699 2,858 120 787 3,178 20 440 2,555 44 220 114 97 311 5,872 2,258 882 333 12 12 201 11 35 174 9 15 90 2 19 76 220 91 462 2,365 3,045 105 617 1,536 121 135 626 116 29 188 52,430 14,599 3,810 3,254 1,865 32,720 222 210 968 12,729 657 471 1,607 2 290 582 9,501 17 113 371 1,605 657 275 864 2 40 103 2,393 11 61 93 402 174 133 254 16 28 127 1,462 17 2 199 812 138 551 58 514 28 .114 2 14 160, Annapolis 12, Baltimore(4)...481 Brunswick 31 Cambridge 8, Crisfield 12 Cumberland 12 Easton 71 Ellicott City 11, Hagerstown 12 Havre de Grace 31 Hughesville 10 Prince Frederick 31 Rockville.. 7, Salisbury 12 5 10 201 1 12 9 1 8 162 1,147 2 53 2 905 282 48 5 91 33 2,508 1,063 1,311 134 1,519 188 1,646 24 43 88 218 19 32 121 16 28 4 28 53 123 808 24 15 60 144 4 122 1 62 14 24 4 23 9 3 61 716 27 28 71 19 28 59 1 4 5 44 1 3 1 224 893 4 6 87 112 14 2 91 19 22 2 6 37 7 40 271 25 23 24 3 46 618 1 275 PUBLIC HEALTH SERVICE Michigan_ Battle Creek Detroit (4) Flint Grand Rapids Highland Park Jackson Kalamazoo Lansing Pontiac (2) Saginaw Minnesota Duluth Minneapolis (2) St. Paul Mississippi Laurel Meridian Missouri Columbia Flat River Hannibal Joplin Kansas City (5) Sedalia Springfield St. Joseph St. Louis (5)_ Montana Great Falls Nebraska Hastings Lincoln Omaha (2) New Hampshire Concord Dover Manchester Nashua New Jersey_ Bayonne Camden Englewood Greystone Park Jersey City Long Branch Montclair Morristown Mount Holly Newark New Brunswick Orange Passaic Paterson (2) PlainfielcL Somerville Spring Lake Trenton Weehawken 11 Microscopic examinations, gonococcus Doses of arsphenamin administered Treatments given Patients discharged as noninfectious Chancroid Syphilis Gonorrhea Patients admitted Total State and city Total monthly reports received TABLE 6.-Report of clinics reporting to State boards of health, July 1, 1925, to June 30, /926-Continued P. a0 O1373 &I3 2 932 128,578 21,313 30,888 28,624 43 567 14 30 11 64 35 93 7 68 160 449 203 159 112,748 17,761 26,434 26,651 521 3,7181 78 1,040 60 455 160 1,2881 15 225, 33 60 32 2,433] 1,217 747 237 1,8191 154 175 159 747 396 1,630 619 529 262 3,521 460 248 170 1,630 152 7,127 3,873 3, 243 12 46 12 12 8 12 12 12 14 12 25 47 72 6,193 3,289 2,904 66 112 181 39 58 98 6 14 20 14 59 73 28 25 58 44 114 158 103 110 215 14 45 59 48 1,198 501 695 2 704 30,3331 8,618 2,954 1,761 12 24 12 524 323 351 187 150 164 336 173 186 1 1 68 101 535 11,215 10,509 8,609 2,198 3,446 2,974 747 1,142 1,065 842 251 668 23 446 350 70 26 217 3,258 2,025 795 309 11 12 223 223 186 164 24 46 13 13 130 87 1,476 1,782 1, 194 831 604 191 43 266 176 4,329 2,950 1,260 119 495 86,136 11, 136 7,541 3,608 12 3 12 6 59 12 12 12 48 28 26 19 25 7 23 18 36 1,751 1, 101 28 86 79 113 121 322 1,945 1,551 2 6 14 15 616 41 33 201 332 2 3 34 17 1 62 13 1 5 34 212 83 91 2 54 374 54 206 596 22,914 1,003 1,822 3,371 55,796 139 32 44 188 6,037 35 439 983 3,239 91 22 16 165 4,710 120 221 358 1,838 24 8 9 185 1, 707 129 116 160 1,270 13 4 8 1 5 238 26 14 25 8 1 5 238 26 14 25 6 3 1 5 2 13 4 48 1,026 498 518 10 413 32,539 8,181 4,614 6,274 12 12 24 18 306 702 4 100 394 14 205 299 1 9 13 106 294 573 15,137 16,829 34 3,473 4,674 14 1,521 3,079 248 3,685 2,341 41 135 77 58 32 7,686 1,947 504 200 12 6 12 11 21 13 77 24 18 11 30 18 3 2 47 61 32 495 89 5,809 1,293 477 44 1,030 396 23 6 200 275 7 3 162 28 2,143 1,264 870 47,878 11,386 6,242 3,325 700 373 421 1,460 1,598 777 1,631 323 335 63 411 1,071 549 331 1, 165 119 19 110 232 162 202 258 47 23 23,892 749 3,764 792 1,896 1,539 167 355 6,901 540 3,607 437 855 3071 487 371 149 259 922 67 2, 110 88 1, 798 145 124 110 21 55 597 45 6 205 11 11 11 11 10 11 11 11 2 11 9 11 11 22 11 8 11 11 11 20 34 34 63 34 50 37 45 1 1,074 56 167 36 41 69 2 38 322 20 17 34 31 40 22 46 35 27 1 524 34 109 33 13 50 2 38 196 12 9 628 3 23 3 23 12 4 2 18 2 61 2 3 9 546 21 57 3 28 17 4 1 1 378 28 12 2 2 125 8 1 57 4 8 36 3 8 78 58 30 2,567 15 234 4 15 2 272 19 276 PUBLIC HEALTH SERVICE New York Albany (4) Amsterdam Auburn Beacon Binghamton Buffalo (2) Cohoes Corning Dunkirk Elmira Glen Falls Gloversville Hornell Hudson Ithaca Jamestown Little Falls Middletown Newburgh New Rochelle Niagara Falls Olean Oswego Plattsburg Port Chester Poughkeepsie Rochester (6) Rome Salamanca Saratoga Schenectady Syracuse (2) Troy Utica Watertown Wellsville White Plains Yonkers_ gorth Dakota Grand Forks Minot Dhio Akron Athens Canton Chillicothe Cincinnati (4) Cleveland (11) Columbus (5) Dayton (3) East Liverpool Hamilton Lakewood Lima (2) Massillon Portsmouth Port Clinton Springfield (2) Toledo (2) Youngstown (2) Dregon Portland 545 48 12 12 11 12 18 12 11 12 12 12 12 11 11 12 12 11 11 12 12 12 12 12 12 12 12 65 12 4 11 12 24 11 12 12 11 11 12 5,864 3,604 2, 194 298 171 50 34 25 23 9 9 92 79 1,943 1,243 9 40 20 28 2 1 115 77 40 25 34 24 16 16 9 6 178 35 66 43 2 100 74 12 7 190 99 87 63 52 35 46 34 23 23 27 22 45 31 669 482 65 40 21 13 15 10 144 59 694 352 45 66 342 187 45 54 22 22 30 28 213 118 120 16 2 13 661 29 7 1 38 15 10 3 143 23 2 26 5 88 24 17 12 5 14 186 25 7 5 79 342 21 155 9 2 89 66 5, 195 7 231 25 2 16 71 39 1, 823 2 37 1 22 3 45 3 1 1 6 6 57 41 5 182 90 15 106 1 209 253 44 26 26 74 80 702 29 2 4 71 375 50 270 31 8 38 131 138,582 42,333 13,061 6,098 2, 166 808 2,298 811 220 122 195 5,441 1, 485 39,660 6,553 496 100 485 169 326 79 2,972 1,344 2,482 892 1,307 973 464 90 56 54 2,597 551 772 2,127 276 38 634 1,945 297 35 1,994 659 2,418 1,502 598 271 2,624 1,668 527 188 892 366 1, 167 534 24,849 13,011 1,123 475 40 115 189 376 3, 198 453 10,801 1, 747 1,460 631 8, 265 1, 289 703 298 174 125 333 268 6,632 1,534 Microscopic examinations, gonococcus Wassermann tests made Doses of arsphenamin administered a m Treatments given Patients discharged as noninfectious 4 .q Chancroid Gonorrhea Patients admitted Total State and city Total monthly reports received TABLE 6.-Report of clinics reporting to State boards of health, July 1, 1925, to June 30, /926-Continued 6,958 829 81 118 42 386 2,995 28 38 30 226 183 55 65 27 142 144 16 107 20 5 2 33 3,887 12 346 274 34 82 51 79 133 3,891 88 14 15 139 1,266 177 426 54 13 42 520 2 241 46 2 31 2 9 102 803 36 2 7 5 40 42 39 3 19 518 36 2 76 372 46 158 8 4 3 250 4 21 37 428 108 33 237 4 1 20 1 36 52 376 24 84 4 29 8 229 463 9, 220 4,957 3,933 330 2,089 12 12 12 12 32 124 59 35 12 11 12 24 12 11 11 24 24 24 973 259 654 29 29 71 48 23 11 11 1,416 897 472 4, 196 1,883 2,099 890 593 295 541 377 163 136 50 83 44 44 5 1 4 25 24 1 111 111 101 101 10 7 2 92 45 137 286 213 71 238 217 21 15 25 3 12 1 24 60 47 214 2 1 3 1 2 191 1 14 7 40 725 646 107 108 33 2 57 72 1 64 7 14 171,832 36,435 26,014 17, 219 23,692 2,416 1,921 1,923 198 1, 340 268 601 293 136 9 77 77 5 23,234 5,453 3,077 696 85, 337 12,209 12,092 12, 576 11,575 3,015 3, 305 877 7,801 4, 262 2,029 258 2,047 394 480 217 29 370 353 100 92 27 24 91 11 1, 594 293 79 2,961 1,441 44 629 1, 739 870 176 4 81 129 49 1, 583 747 242 263 96 3,431 2,014 635 4, 277 2, 104 1,017 15 11 333 200 133 5,423 1,451 732 734 11 333 200 133 5,423 1,451 732 734 277 PUBLIC HEALTH SERVICE South Carolina Orangeburg Spartanburg South Dakota Aberdeen Sioux Falls Tennessee Chattanooga Dyersburg Franklin Knoxville Memphis Nashville (2) Sevierville Trenton Union City ,.- 6 13,859 6,043!5,695 4, 783 12 18 59 2 15 341 2,524 10,714 265 194 549 5,075 225 17 19 188 5,417 54 5 69 4,689 20 593 7,347 1, 249 183 1, 709 354 239 286 7, 061 120 1, 129 28 155 1, 709 91 2 19 3 15 50 28 195 360 35 93 32 55 33 44 13 62 3 80 23 155 108 22 15 11 24 841 16 26 201 1011 271 31 131 62 2 2 18 5 151 313 7 196 4 262 29 1 13 42 3 46 15 340 52 636 351 285 4 23 49 541 19 4 20 29 282 16 3 20 259 3 513 209 298 8 8 1 6 4 _.... 6 Microscopic exami- 1 nations, gonococcus 4 12 12 36 12 2, 361 1,078 349 175 1, 155 153 85 539 535 43 5, 556 3,073 741 448 1,836 413 395 1,260 194 590 7681 l,6281 468 2,990 942 1,423 352 1,787 792 483 373 2,624 66 31 518 949 9,006 8, 180 688 5, 744 326 6, 322 1, 323 859 273 1,881 67 1,017 408 11,907 1,448 24 2 7 tests 76 37 865 103 60 46 121 20 82 380 1,815 213 256 171 90 27 115 31 16 49 34 48 55 58 38 198 88 41 44 192 70 24 30 114 2 2 68 33 346 671 42 289 36 317 60 45 26 105 6 96 38 496 160 5 46 126 17 21 22 18 11 10, 571 4,627 3,346 7 1 3 2 24,815 1,293 135 78 64 343 121 48 51 34 101 189 132 333 420 854 102 97 968 654 308 343 128 114 85 131 310 706 168 272 268 33 71 204 191 682 18 32' 2 4 82 300 183 549 941 2, 510 713 2, 735 20 414 72 2 80, 149 Wassermann made 123 57 35 13 7 7 Doses of arsphenamin administered 2, 191 133 114 55 14 111 24 16 25 34 26 39 45 14 114 72 15 24 92 43 22 17 52 Treatments given 2,440 256 171 95 27 118 31 16 51 34 51 54 56 40 198 95 42 47 195 71 25 30 125 2 2 68 33 348 680 42 297 36 325 62 46 26 104 6 102 38 499 160 Chancroid Gonorrhea Arctic Newport Pawtucket Providence (3) Woonsocket Syphilis Rhode Island 4, 703 12 12 12 12 12 12 10 12 12 10 11 12 12 12 12 12 12 12 24 12 9 11 • 4 4 12 12 12 12 12 12 11 12 12 12 10 11 12 12 11 24 12 486 Pennsylvania Allentown Altoona Beaver Falls Bedford Bethlehem Butler Carlisle Chambersburg Clearfield Coatesville Connellsville Du Bois Easton Erie Greensburg Hazleton Huntingdon Johnstown Lancaster (2) Lebanon Lewistown McKeesport Meadville Miltintown New Castle Norristown Philadelphia Pittsburgh Pottsville Reading Rochester Scranton Shamokin Sharon Stroudsburg Sunbury Tunkhannock Washington West Chester Wilkes-Barre (2) York Patients admitted Total State and city Patients discharged as noninfectious Total monthly reports received TABLE 6.-Report of clinics reporting to State boards of health, July 1, 1925, to June 30, 1926-Continued 62 41 244 87 41 9 156 11 6 1 57 68 11 336 554 1 327 4 296 19 10 1 50 17 74 223 961 377 433 87 378 17 377 50 3, 579 743 3 3 99 414 36 173 63 235 8 10 4 6 10 245 96 37 48 4 4 7 3 2 2 5 1 1 9 136 109 19 77 30 7 19 29 53 4,090 2,397 1,224 2,335 59,475 18,053 21,990 4,923 3 2 2 272 805 1,248 2 69 26 26 19,803 23,272 16,085 45 107 42 42 15 26 3,602 11, 166 3, 104 21 59 18 18 11 13 1,311 19, 118 1, 475 9 30 5 5 2 1 2 12 12 18 2 2 2 11 6 5 787 1,848 1,411 6 10 6 7 4 5 380 1,439 546 4 8 4 . 6 469 3 2 1 373 327 514 1 2 2 34 82 351 1 1 1,361 1,397 2, 149 5 3 3 278 PUBLIC HEALTH SERVICE 11 - 11 Ia> tests 1 Fl Microscopic examinations,gonococcus I., co "a Wassermann made 4 Doses of arsphenamin administered Patients discharged as noninfectious .4 - Chancroid Gonorrhea State and city Patients admitted Total Total monthly reports received TABLE 6.-Report of clinics reporting to State boards of health, July 1, 1925, to June 30, /926-Continued Dallas El Paso Houston_ San Antonio • 40 2/850 1,650 11 7 11 11 56 51 270 157 1,837 1,069 687 373 42,346 11,697 7,245 12,032 5 103 506 294 4 10 206 262 1,494 20 55 875 6, 235 18,963 16, 273 862 1,022 4,688 5, 125 1, 109 775 3,961 1,400 20 681 3, 167 8, 164 22 601 378 213 55 7 15 133 218 250 38 144 196 45 105 63 1 52 2 20,678 11,865 10,605 3, 105 1,759 co rexas 24 35 29 6 7 10 7 4 20 11 3 15 11 1 5 95 2,255 1,639 565 12 12 12 12 3 9 12 12 11 260 56 198 87 123 76 311 1,028 116 Washington 36 1, 161 564 586 11 538 Seattle Spokane Tacoma 12 12 12 809 286 66 387 145 32 411 141 34 11 210 299 29 1,636 1,026 544 66 Vermont Barre Burlington (2) Rutland Virginia Charlottesville Danville Lynchburg Newport News Norfolk Norton Petersburg Richmond Roanoke West Virginia Alderson Bluefield Charleston Clarksburg Grafton Huntington Kingwood Logan Martinsburg Moundsville Parkersburg Richwood Wheeling Wisconsin Beloit Green Bay Janesville Kenosha La Crosse Madison Milwaukee (3)_ Oshkosh Racine Superior Wausau Wyoming Casper 112 260 51 73 78 95 59 255 675 93 5 93 9 28 17 52 338 23 5 7 12 12 1 12 11 12 3 6 7 12 12 10 15 619 108 1 271 13 285 20 79 7 11 197 10 12 388 86 156 1, 521 799 714 12 12 12 12 12 12 36 12 12 12 12 52 14 37 27 80 110 1,049 25 49 37 41 22 10 9 17 25 36 614 14 21 19 12 30 4 28 10 55 74 427 11 28 18 29 6 10 4 6 10 4 176 7 159 8 45 5 11 119 2 220 22 1 84 6 84 12 34 1 51 32 4 15 1 11 11 42 1 78 8 794 2,100'2,100 586 444 638 638 3,928 1, 478 1,245 399 653 1, 510 3,377 2,328 6, 269 3, 240 1,026 585 5,367 183 240 425 523 235 732 2, 748 152 21,029 2,848 6,985 7, 733 9,520 10, 110 1,399 1,403 1, 161 284 5, 555 1,266 165 5, 197 2,105 431 466 18,093 7, 206 3, 227 1,888 15 113 151 10 16 10 123 16 118 150 4,273 3,762 66 3, 765 137 2,048 97 98 82 1, 180 1,617 17 2,017 117 456 32 24 30 1,092 256 4 738 12 493 10 6 ' 24 579 401 13 334 23 91 28 165 274 3,238 136 274 1,180 25 20 523 382 18 261 79 106 88 26 60 156 1 10 1. 8 347 222 253 27 123 2, 125 7 306 13,639 6,472 10, 158 5,163 36 1 7 21 18 25 108 15 39 4 32 868 77 592 223 1, 187 1,548 6,655 517 353 1, 112 507 327 43 24 140 187 394 4,660 224 173 223 77 40 27 93 260 254 216 8,758 98 160 163 89 4 10 99 90 563 214 3,655 102 112 122 192 6 4 319 93 23 18 6 4 319 93 23 18 8 279 PUBLIC HEALTH SERVICE TABLE 7.-States ranked according to the monthly and daily new admissions per clinic, July 1, 1925, to June 30, 1926 Rank Monthly Daily average average new ad- new admissions missions per clinic per clinic State United States__ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 South Carolina Louisiana Tennessee Texas Alabama Michigan California Arkansas Georgia Illinois Kentucky Washington Oregon Florida Minnesota Missouri Virginia Nebraska Ohio 22.9 0.8 85.5 78.5 77.2 71.3 63.7 46.9 46.5 46.2 43.1 33.8 33. 1 32.3 30.3 25.4 25.0 24.6 23.7 21.4 19.9 2.9 2.6 2.6 2.4 2.1 1.6 1.6 1.5 1.4 1.1 1.1 1.1 1.0 .8 .8 .8 .8 .7 .7 State Rank 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 Monthly average new admissions per clinic Mississippi Indiana Maryland West Virginia Connecticut New York Colorado New Jersey Wisconsin Pennsylvania Rhode Island ______ __ Delaware Kansas Maine New Hampshire Montana North Dakota Wyoming Vermont South Dakota 19.4 16.4 15.7 14.6 12.3 10.8 10.5 10.5 9.8 9.7 8.4 8.3 7.9 5.0 3.3 2.2 1.7 1.7 1.5 1.3 Daily average new admissions per clinic 0.6 .5 .5 .5 .4 .4 .4 .3 .3 .3 .3 .3 .3 .2 .1 .1 .1 .1 .1 .1 NOTE.-No clinic reports from Arizona Idaho. and Massachusetts. Iowa, North Carolina, Oklahoma, and Utah did not report in 1926. TABLE 8.-State report of doses of arspitenamin (or similar product) administered, July 1, 1925, to June 30, 1926 State Doses administered 651,785 United States Alabama Arizona 1 Arkansas California Colorado Connecticut Dolaw are District of Columbia 1 Florida_ Georgia Idaho 2 Illinoias Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts 2 Michigan Minnesota Mississippi Missouri 1 Not reporting. 2 For 11 months only. For 6 months only. 47,384 16, 250 55,096 2,472 16,917 1,488 5,882 35, 104 614 48,761 24,701 5,802 14,462 19,944 2,353 14,987 50.064 21,919 8,618 14,487 26,258 State Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon' Pennsylvania Rhode Island South Carolina 4 South Dakota Tennessee Texas 2 Utah' Vermont' Virginia Washington West Virginia Wisconsin Wyoming 4 For 3 months only. For 7 months only. Doses administered 21 9,602 1,957 12,804 43,451 108 44,601 1, 512 26, 353 6,406 2, 125 96 18,053 20,446 378 11,933 4,563 7,248 6,472 93 280 PUBLIC HEALTH. SERVICE TABLE 9.-Report of 33 correctional and penal institutions, 1926 Patients admitted: Syphilis Gonorrhea Chancroid 3,517 4,063 133 Total 7,713 Patients discharged as noninfectious Treatments given Doses of arsphenamin administered Wassermann tests made Microscopic examinations for gonococcus infection 4,301 276,084 24,555 45,139 8,766 TABLE M.-Statistical summary of activities in the control of venereal diseases for the fiscal years 1925 and 1926 1926 1925 Medical activities A. Cases of venereal diseases reported to State boards of health: I. Syphilis II. Gonorrhea III. Chancroid Total 215,547 166,655 7,029 1 201,692 1 166,208 1 6, 742 189,231 1374,642 B. Doses of arsphenamin (or similar product) distributed by State boards of health _ 651,785 683,591 C. Clinics: I. Clinics established during the year 2 23 34 II. Clinics reporting to State boards of health 416 495 III. Reports from clinicsa. Patients admitted 100, 776 110,372 b. Patients discharged as noninfectious 44,329 47,828 c. Treatments given 1,881,380 2,088,494 , d. Wassermann tests made 291,803 300,362 e. Microscopic examinations for gonococcus infection 188,674 203,512 D. Requests for medical information received by the Public Health Service 640 658 Educational activities A. Pamphlets: I. Requests for pamphlets received by thea. Public Health Service b. State boards of health from1. Public Health Service for compliance 2. The public Total 12,235 11,862 9,986 28,891 9,334 29,801 38,877 39,135 c. Gross total requests for pamphlets received Minus requests received by State boards of health from the Public Health Service 51,112 50,997 9,986 9,334 d. Net total requests for pamphlets received 41, 126 41,663 4,711 41,303 29,208 29,357 46,014 969,592 58,565 971,003 c. Gross total pamphlets distributed 1,015,606 Minus pamphlets distributed by the Public Health Service to 4,711 State boards of health 1,029,568 d. Net total pamphlets distributed 1,010,895 1,000,360 731,044 784,560 II. Pamphlets distributeda. By the Public Health Service to1. State boards of health 2. Others Total b. By State boards of health III. Pamphlets and placards purchased and reprinted by State boards of health_ IV. Educational venereal disease pamphlets issued by the Public Health Service V. Revisions of venereal disease pamphlets issued by the Public Health Service 29,208 2 4 1 21 1 Changed from previously published 1925 figures because of additional data received after publication of the 1925 annual report. 2 National Negro Health Week Bulletin, 1925 edition. 281 PUBLIC HEALTH SERVICE TABLE 10.—Statistical summary of activities in the control of venereal diseases for the peal years 1925 and, 1926—Continued 1926 1925 Educational activities—Continued B. Lectures and addresses: I. Lectures and addresses reported by the— a. Public Health Service b. State boards of health Total II. Average attendance reported by the— a. Public Health Service b. State boards of health Average attendance at total lectures III. Lectures at which exhibit material was used, reported by— a. Public Health Service b. State boards of health Total C. Exhibits and lantern slides: I. Exhibits and lantern slide sets loaned by the Public Health Service to— a. State boards of health b. Public Health Service field officers c. Others Total II. Exhibits and lantern slide sets purchased and borrowed by State boards of health III. Exhibit and lantern slide showings reported by State boards of health IV. Average attendance reported by State boards of health D. Motion picture films and strip films: I. Motion picture films loaned by the Public Health Service to— o. State boards of health b. Public Health Service field officers c. Others Total II. Motion picture films purchased and borrowed by State boards of health III. Motion picture showings reported by State boards of health IV. Average attendance reported by State boards of health V. Strip films loaned by the Public Health Service to State boards of health E. Publicity material, Public Health Service: I. Articles furnished magazines 134 4,133 230 4,779 4,267 5,009 137 109 158 111 110 113 72 391 135 602 463 737 14 2 55 78 22 59 71 159 97 778 252 98 742 473 7 8 .4 7 9 19 35 404 202 405 19 643 221 25 33 DIVISION OF PERSONNEL AND ACCOUNTS In charge of Asst. Surg. Gen. J. W. KERR In order to conform to requirements of the President with respect to economy in expenditures, special attention has been paid during the year to office procedure as relates to personnel and accounts. This has been improved wherever practicable. Since practically all matters of personnel and accounts relating to the care of ex-service men and women have now been adjusted with the Veterans' Bureau following the transfer of this function to that bureau, certain changes of procedure naturally followed. The remaining records, pertaining to personnel especially, have been corrected and the methods of keeping these records stabilized. While it is impracticable fully to apply ordinary business methods in Government procedure—there are too many legislative and administrati7e restrictions to permit this—progress has been made in the simplification of the records and the methods of keeping them. Reductions of expenditures brought about in this way have been in large measure offset, however, by additional duties and responsibilities imposed by law on the service. The extension to continental European ports of the medical examination of intending emigrants, in connection with the granting of consular visas has caused a heavy draft on the number of commissioned medical Officers of the regular corps heretofore available for other service activities in the United States. Since the inception of this work, at ports of Great Britain and the Irish Free State, in A.ugust, 1925, a total of 28 officers has been ordered to various points in Europe for duty. The practical value of making these medical examinations before the granting of visas has been demonstrated to the satisfaction of the State and Labor Departments and Immigration Service and Public Health Service officials during the past year. The necessity for selecting medical officers with the requisite experience, especially in mental examinations, has added to the personnel problems of the bureau. Congress has recognized the situation by authorizing 10 additional officers to replace those sent to Great Britain early in the year. When it was decided that on account of the success of the medical examinations in Great Britain they should be extended to countries of continental Europe, provision was also made in a deficiency appropriation of July 3, 1926, in amount $36,198, to supplement the appropriation,"Pay of personnel, etc., 1926," for 15 additional medical officers. Every effort has been made to recruit these officers and assign them to duty at regular stations in the United States and thus 282 PUBLIC HEALTH SERVICE 283 relieve experienced commissioned officers for the inauguration of the medical examinations of intending aliens at continental ports. The appropriation act for 1927 had been passed, however, without provision for the inauguration of this work. This will necessitate, therefore, a deficiency appropriation for 1927, the estimate for which has been prepared. It is pertinent here to state that at the present time more than 25 per cent of the commissioned officers of the regular corps on active duty are engaged in foreign service, either in connection with immigration or quarantine activities. An act approved May 8, 1926, provided that the pay of retired officers who had been retired on or before June 30, 1922, should not be less than that provided for officers of equal rank and length of service retired subsequent to that date. The pay of 14 officers of the service on permanent waiting orders was increased by the passage of this act from the date of its passage. On account of the additional laws or modification of laws pertaining to the service and because of changes of procedure previously referred to, the regulations for the Government of the United States Public Health Service were thoroughly revised during the year and approved by the President February 9, 1926. The new regulations became effective April 1, 1926. During the year the property accounting regulations have been rewritten and made uniform for all stations. Surplus property at stations has been made available to other stations, and transfers effected to the stations where most needed. In addition, quantities of surplus property, much of which originated from surplus stocks of the War Department, have been transferred to other Government departments and establishments. All unserviceable property has been inspected and sold whenever it had a sale value. Property of the service is all accounted for and complete records kept from the time it is acquired until finally disposed of. The administrative and clerical work of this division in the bureau has perhaps reached a greater volume, in proportion to the number of persons employed therein, than at any time in the past. Much of this work is due to the installation and operation of record-keeping systems necessitated by requirements of the General Accounting Office. The insistence of that office on changes in procedure .in conformity with its interpretation of the law has required modifications of methods in the handling of both personnel and accounting records which have for many years proved efficient and economical. The inauguration of certain new standard forms, while perhaps desirable from an accounting standpoint, has in numerous instances greatly increased the clerical work incidental to their use. There can be no doubt that further detailed work of this kind will require the employment of additional clerical personnel. The additional clerical work imposed is also beginning to result in requests for additional clerical personnel at the larger field stations. Early in the fiscal year (July 16, 1925) the Comptroller General rendered a decision in connection with the compensation of certain employees in the Department of Commerce and the Department of the Interior to the effect that the furnishing of any allowances in the nature of quarters, subsistence, laundering, etc., to civil employees was contrary to law, on the theory that salaries had been adjusted by the heads of departments and establishments under the act of De14656-26 19 284 PUBLIC HEALTH SERVICE cember 6, 1924, to correspond as nearly as might be practicable to the rates of pay provided for departmental employees by the classification act of 1922; that such salaries became thereupon "fixed by law"; and that the furnishing of additional allowances in kind therefore constituted a violation of section 1765,Revised Statutes. The decision stated that in view of the long-standing practice no objection would June 30, 1926, after be raised to furnishing such allowances prior to' which time, unless express statutory authority had been secured, the practice must be discontinued. Since a large proportion of Public Health Service employees in the field are furnished quarters, subsistence, and laundering, a letter was addressed to the Comptroller General by the Secretary of the Treasury on July 22, 1925, setting forth the effect of his decision on the Public Health Service personnel, and explaining that for many years it had been customary under the regulations to furnish employees whose presence on the station was necessary to its operation with quarters, subsistence, and laundering. It was further stated that the value of such allowances had been considered in adjusting the cash pay of such employees, and that the allowances were always 'specified in the recommendation for appointment, thus constituting a part of the contract of employment. In response to this letter a reconsideration of the decision, dated August 31, 1925, was given. The situation with regard to Public Health Service personnel was given recognition and it was stated that the existing procedure could continue throughout the fiscal year undisturbed. The decision that express statutory authority would be required for its continuance after June 30, 1926, was reiterated, and a further requirement was added that the value of all allowances furnished in kind should be shown on pay rolls and the retirement deduction (then 21/2 per cent) should be calculated on the added value of allowances and cash compensation. Beginning with the month of October this requirement was carried out, the value of allowances being fixed at specified rates for various employees by the Secretary of the Treasury. The necessity of furnishing allowances in kind in the various field services of the Government was promptly recognized by Congress, and the act of March 2, 1926, making appropriations for the Treasury and Post Office Departments for the fiscal year 1927 contained the following language: The head of an executive department or independent establishment, where in his judgment conditions of employment require it, may continue to furnish civilians employed in the field service with quarters, heat, light, household equipment, subsistence, and laundry service; and appropriations for the fiscal year 1927 of the character heretofore used for such purposes are hereby made available therefor: Provided, That the reasonable value of such allowances shall .be determined and considered as part of the compensation in fixing the salary rate of such civilians. Another decision of the Comptroller General, relating to the transportation of the personal effects of officers and employees on permanent change of station, also necessitated relief by congressional action. The decision relating to the cost of transporting the household goods and other personal effects of employees, when ordered to make permanent change of station, was rendered originally in the case of certain field employees of the Department of the Interior, under date of March 28, 1925. (4 Comp. Gen. 818.) PUBLIC HEALTH SERVICE 285 Although the payment of such expenses had been authorized for commissioned officers, scientific personnel, pharmacists, and administrative assistants for years under presidential regulations, the bureau received verbal notice from the General Accounting Office that unless express legal authority for such expenditures were secured by June 30, 1926, they would no longer be allowed. Accordingly, in connection with the 1927 estimates, request was made for language in the appropriation which would protect those employees already receiving the allowance, by regulation. on change of station. The Treasury Department approved the language submitted, but the Bureau of the Budget declined to include either scientific personnel or administrative assistants in the wording of the estimates as transmitted to Congress. These two classes of field personnel, who are appointed for general field duty and are subject to change of station, are thus subjected to an expense which was formerly defrayed by the Government and which they doubtless considered in connection with the compensation of the positions when many of them entered the service. Consideration of this fact will necessarily act as a deterrent to the bureau in ordering changes of station in future even when the best interests of field work would be served thereby. PUBLIC HEALTH DISTRICTS During the year Senior Surg. E. K. Sprague has continued to serire as acting director of district No. 1, in the absence of Asst. Surg. Gen. Rupert Blue, who has remained on special duty in connection with the eradication of plague in California. Doctor Sprague has discharged the duties of director in addition to serving as medical officer in charge of United States Marine Hospital No. 70 for a part of the year, and later as chief medical officer at Ellis Island, N. Y. The office of the director was moved from 370 Seventh Avenue to 45 Broadway during the year. The latter building, Government owned and under the control of the United States Shipping Board, affords increased accommodations at a considerable reduction in cost of rental, the latter being prorated on an actual cost basis among the various Government activities housed. Under the director in district No. 1 Chief Pharmacist W. L. Stearns has been in immediate charge of the work of assistant to the coordinator for supply, a function which the office of the district director has for several years discharged in the New York area. Mr. Stearns has also acted as special disbursing agent. The solicitation of proposals for furnishing subsistence supplies for stations in the New York City area has been conducted on a monthly basis, and supplies other than subsistence have been solicited quarterly. United States Veterans' Hospital No. 81, in New York, has utilized the subsistence proposals for securing supplies, provision being made in the solicitation of the proposals for this purpose, and both services thus securing the advantage of increased quantity purchasing. Coordinated purchasing for all Public Health Service stations in the area has again proved satisfactory and economical. The inspection of supplies, conducted by inspectors detailed from the meat inspection division of the local office of the Bureau of Animal Industry and the Bureau of Agricultural Economics, has been productive of good results and has insured the quality of all 286 PUBLIC HEALTH SERVICE supplies such as meats, poultry, fish, and dairy products delivered on contracts. The office of the district director in New York has also acted on 133 requisitions submitted by the Bureau of Supply in Washington and by Public Health Service stations in the New York area, preparing the specifications and soliciting the proposals for the supplies requisitioned. Surg. B. S. Warren has continued as director of district No. 2, with headquarters at Baltimore, Md. During the year inspections were made of all service stations and activities in the district, including marine hospitals at Baltimore, Md.; Pittsburgh, Pa.; Norfolk, Va.; Louisville, Ky.; and Memphis, Tenn. Twenty-two relief stations, the Public Health Service supply depot at Perry Point, Md., and the United States Coast Guard supply depot at Arundel Cove, Md., were visited, as were 8 quarantine stations, 5 immigration stations, the service trachoma hospital at Knoxville, Tenn., and 4 field stations of the Division of Scientific Research. Numerous recommendations were made with a view to consolidation and coordination of the work at stations visited, many of which have resulted in substantial economies. During the year the relief station maintained at Lee Hall, Va., to render service to men on board the laid-up fleet, was discontinued on recommendation of the district director. Fourteen physicians, who furnish relief to officers and men of the Coast Guard, under contract arrangements were visited during the year. Charges against an employee at the Memphis (Tenn.) Marine 'Hospital, and apparent shortages in the delivery of ice to the Hygienic Laboratory at Washington were also investigated and report made thereon. The visiting of all field stations by the director of the second district has been productive of excellent results, especially in the conduct of the smaller stations which have been brought into closer contact with the bureau, and which have been rendering an improved service. Senior Surg. C. C. Pierce has served throughout the year as director of district No. 3, with headquarters at Chicago, Ill. During the year inspections were made of 11 relief stations, 4 immigration stations, and 3 contract stations for the relief of Coast Guard personnel. The Marine Hospitals at St. Louis, Evansville, Ind., Cleveland, and Chicago were also inspected, and the disposal of unserviceable property at these hospitals arranged for.. The trachoma hospital at Eveleth, Minn., was also visited. Conferences with service officers regarding the conduct of the work were held at all of these stations. The director served on four entrance-examination boards, three immigration boards, two boards for the examination of reserve officers, and as chairman of a board to examine proposed sites for a new marine hospital at Detroit, Mich. Numerous meetings of associations for the promotion of public health in Chicago and elsewhere in the third district were attended • during the year. These included a meeting of the health officers of Illinois, at which an address was, given on "Control methods of smallpox"; four meetings of the Chicago Regional Planning Association, at which the director acted as chairman of the health sec- PUBLIC HEALTH SERVICE 287 tion a meeting of the Cook County Health Association, where an address was made on "Practical application of public-health education ", a community health pageant at RavensNtrood, Ill., where the director was principal speaker at a public meeting; ana meetings of the Chicago Pneumonia Commission, the Chicago Social Hygiene Council, the Conference on Medical Education of the American Medical Association, and the annual meeting of the American Public Health Association in St. Louis, Mo. Conferences were held with the State health officers of Wisconsin, Minnesota, Kansas, Indiana, Ohio, Kentucky, Missouri, South Dakota, and Iowa, and also upon several occasions with officials of the American Medical Association regarding public-health matters. The director also served for a part of the year as president of the Chicago Federal Business Association, and on request of local authorities served as a member of the Chicago Civil Service Examining Board, holding examinations on technical subjects for positions in the Chicago Health Department. He assisted in the organization of a committee on health education and the school child, on request of the commissioner of health of Chicago. On April 4, Senior Surgeon Pierce was ordered to Washington to assume charge of the preparation of the Public Health Service exhibit for the Sesquicentennial Exposition in Philadelphia. He was given entire supervision of the collection and preparation of exhibit material, models, etc., and arrangements for its shipment and installation. The completion of this duty occupied his entire time during the months of April, May, and•June. Throughout the year Surg. John McMullen has served as director of district No. 4, with headquarters at New Orleans, La. Until September 30, 1925, he was also in charge of the rodent-plague survey at New Orleans and other Gulf ports, conducted for the purpose of determining the extent of bubonic-plague infection among rats. On the latter date this work was Successfully terminated. During the year the marine hospitals at Mobile, Ala., Carville. La., and Key West, Fla., were visited and inspected. Eleven rend stations within the district were also visited, as well as the trachoma hospital at Russellville, Ark. In addition, 23 quarantine stations were visited and inspected. In a number of cases recommendations for the consolidation of relief and quarantine functions were made, which resulted in substantial economies. On recommendation of the director the relief station maintained at Little Rock, Ark., and the quarantine station at Texas City, Tex., were discontinued. Rearrangement of personnel engaged in relief and quarantine wbrk at Gulfport, Miss., effected a material reduction in expenditures. A survey was made of property belonging to the War Department at Miami, Fla., with a view to the establishment of a quarantine station at that place, and marine hospital facilities when the present rapid growth of the city justifies it. During the past winter the prevalence of smallpox in Florida resulted in the imposition of a quarantine against Florida traffic by the government of the Bahama Islands, and the director was sent to Florida to assist State health authorities in preventive measures medical so as to have the quarantine raised. A commission of three director the ied accompan and State the officers from Cuba visited 288 PUBLIC HEALTH SERVICE through sections they desired to visit. They expressed themselves entirely satisfied with the work being done to prevent the spread of smallpox., The director reports conditions on the Texas-Mexican border with regard to quarantine procedure and facilities as greatly improved. The director represented the service at a conference on mosquito eradication held in New Orleans on October 14, 1925, and by invitation addressed the meeting of the Louisiana State Medical Association held at Monroe, La., last April, on "The activities of the United States Public Health Service in the South." Senior Surg. J. C. Perry has served as director of district No. 5 throughout the fiscal year, with headquarters at San Francisco, Calif. Inspection of all stations in the district was accomplished during the year, the larger stations being inspected twice. Four State institutions in which insane beneficiaries of the service are treated were also inspected. Complaints of beneficiaries at two service hospitals were investigated and reports made thereon. The district director also served as chairman of several boards convened for examination of officers for entrance and promotion and during the illness of the medical officer in charge assumed temporary charge of the San Francisco Marine Hospital. Cooperation with State and local health authorities has been maintained and conferences held with county horticultural commissioners in California on the general problem of ground-squirrel eradication in relation to control of bubonic-plague infection. The director of the district was requested to serve on the committee of public health and sanitation of the regional planning commission, in cooperation with the State health officer of California and the city health officer of San Francisco. Because of the smallpox situation in California, a survey was made to determine the practicability of the medical inspection and vaccination of crews taken to Alaska for work in the salmon canneries, and after correspondence with the bureau it was decided to undertake the physical examination and vaccination of this personnel. During the months of April and May 3,841 persons were examined and vaccinated, of which number 23 were rejected. The smallpox situation in California also resulted in the certification and vaccination of all passengers destined for Hawaiian ports to meet the requirements of the Territorial health authorities. The district director had supervision of this work, and a uniform procedure was instituted at San Pedro, San Diego, Los Angeles, and San Francisco. Senior Surg. G. M. Magruder has served as district director in district No. 6 throughout the year. All first, second, and third class relief stations and quarantine stations and subports were visited and inspected. The director reports a marked improvement in service procedure at quarantine stations. Numerous conferences were held with representatives of the Chamber of Commerce of Tacoma, Wash., regarding the advisability of inaugurating cyanide fumigation at that port as practiced at Seattle. As in the fifth district, measures were taken to insure the certification and vaccination of persons destined for Alaska, particularly cannery employees. The commissioner of health of Alaska expressed PUBLIC HEALTH SERVICE 289 appreciation of the steps taken to prevent the introduction of smallpox which had prevailed on the Pacific coast. Complaints from the Seattle Chamber of Commerce regarding the inconvenience to passengers from foreign ports resulting from quarantine inspection were investigated and the matter settled to the satisfaction of all concerned. A survey of the medical inspection of immigrants was made, with a view to effecting a readjustment of salaries of acting assistant surgeons appointed for such work. A visit was also made to Port Angeles, Wash., with a view to effecting an advantageous rental arrangement with regard to the marine hospital reservation at that place, and an investigation was made as to the desirability of securing the United States Army reservation at Port Townsend, Wash., to be used for quarantine purposes in lieu of the present site. nd An inspection was also made of the customhouse at Port Townse l. hospita marine a as use to ascertain the feasibility of its All of the duties of the district director in the sixth district have been carried on in addition to his detail as medical officer in charge of relief, quarantine, and immigration activities at Seattle. COMMISSIONED MEDICAL OFFICERS • GenOn July 1, 1925, the regular corps consisted of the Surgeon 132 s, surgeon senior 21 large, at general ns surgeo nt assista 4 eral, Of surgeons, 20 passed assistant surgeons, and 23 assistant surgeons. large, at general ns surgeo nt assista 3 201, ating aggreg , this number on 9 senior surgeons,4 surgeons, and 3 passed assistant surgeons were s change ing follow the year fiscal the During orders. g waitin the occurred in the several grades: One surgeon was promoted to on placing the by created y vacanc a fill to n surgeo senior grade of nt permanent waiting orders of 1 senior surgeon; 5 passed assistans surgeo nt assista 6 n; surgeo of grade the to ed promot were suregons were promoted to the grade of passed assistant surgeon; 19 candisucdates for appointment to the grade of assistant surgeon werereguthe and law by bed prescri cessful in the entrance examination senior lations of the service and were commissioned in that grade 1 ity; disabil l physica of because surgeon was placed on waiting orders from 2 passed assistant surgeons and 2 assistant surgeons resigned g orders, waitin on n 1 surgeo , the service; 1 assitant surgeon general and 1 assistant surgeon died. On June 30, 1926, after these changes had occurred, the regular corps consisted of the Surgeon General, 3 assistant surgeons gennt eral at large, 22 senior surgeons, 135 surgeons, 19 passed assistant assista 2 , officers 213 these Of s. surgeon nt assista 33 surgeons, and 3 surgeons general at large, 10 senior surgeons, 3 surgeons, and orders. g waitin on date that on were ns surgeo nt passed assista by At the close of the fiscal year 1926, 7 surgeons were serving the of ns divisio of charge in general ns surgeo nt detail as assista July bureau in accordance with the acts approved July 1, 1902, and s. surgeon 3 senior large, at n general surgeo nt 9, 1918. One assista dishealth public the of rs and 2 surgeons were on duty as directo officer.in tricts. One senior surgeon relieved a surgeon as medicalquarantine ng outgoi of general charge of the enforcement in Europe destined to measures applicable to vessels, their crews, and emigrants 290 PUBLIC HEALTH SERVICE ports in the United States and its dependencies, and assumed charge of the medical inspection in Europe of aliens in connection with the granting of consular visas. One surgeon was on detail as chief surgeon, Bureau of Mines, Department of Commerce, and 1 surgeon and 1 assistant surgeon were serving (the surgeon as medical director) on detail to the United States Employees' Compensation Commission. RESERVE OFFICERS On July 1, 1925, the reserve commissioned officers on active duty numbered 68, this number being composed of 1 assistant surgeon general, 1 senior surgeon, 4 surgeons, 3 dental surgeons, 15 passed assistant surgeons, 11 passed assistant dental surgeons, 28 assistant surgeons, and 5 assistant dental surgeons. On July 1, 1926, after the changes had occurred, the number of reserve officers on active duty was 64, consisting of 1 assistant surgeon general, 4 surgeons, 4 dental surgeons, 11 passed assistant surgeons, 12 passed assistant dental surgeons, 26 assistant surgeons, and 6 assistant dental surgeons. There were on inactive status at the close of the fiscal year 6 assistant surgeons general, 43 senior surgeons, 101 surgeons, 2 dental surgeons, 49 passed assistant surgeons, 1 passed assistant dental surgeon, 43 assistant surgeons, and 1 assistant dental surgeon, the total number 246. ATTENDING SPECIALISTS On July 1, 1925, there were 156 attending specialists in the service, and during the year this number increased to 167, of which number 142 were consultants to marine hospitals, while 25 were available for call at second and third class relief stations. ACTING ASSISTANT SURGEONS On July 1, 1925, there were 496 acting assistant surgeons in the Public Health Service, and by July 1, 1926, this number had decreased by 13. Of the 483 acting assistant surgeons on duty July 1, 1926, 102 were on duty at marine hospitals, 293 were engaged in immigration, relief, and maritime, border, insular, and foreign quarantine work, while 3 were engaged in the prevention of trachoma; 17 were on duty in connection with field investigations of public health and rural sanitation; 1 was engaged in national-park sanitation; 16 were on detail with the United States Coast Guard; 5 were serving with the Bureau of Mines by detail; and 46 were engaged in antivenereal-disease activities as part-time employees at nominal compensation. Seventeen of the 46 acting assistant surgeons engaged in antivenereal-disease activities held appointments as collaborating epidemiologists. INTERNES On July 1, 1925, there were 18 internes in the service, 4 of whom were students, and on July 1, 1926, there were 16. Internes are appointed locally under paragraphs 91 and 92 of service regulations for temporary periods of one year for duty at marine hospitals. PUBLIC HEALTH SERVICE 291 CONTRACT DENTAL SURGEONS On July 1, 1925, there were 29 contract dental surgeons employed at marine hospitals and second and third class relief stations. These part-time employees are appointed for local duty to receive fixed and uniform fees for dental work performed for service beneficiaries. At the close of the fiscal year 8 contract dental surgeons were at marine hospitals and 23 were at second and third class relief stations. EPIDEMIOLOGISTS The number of collaborating and assistant collaborating epidemiologists was increased slightly during the fiscal year. These employees are health officers or employees of State or local boards of health, who receive only nominal compensation from the Federal Government and who furnish the service with reports of communicable diseases received by State or local health organizations. During the year the number of collaborating epidemiologists remained at 42, these appointees being on duty in the different States, and the number of assistant collaborating epidemiologists was increased from 4,258 to 4,419. Eighteen of the collaborating epidemiologists also hold appointments as acting assistant surgeons under the division of venereal diseases. HYGIENIC LABORATORY At the close of the fiscal year the personnel of the Hygienic Laboratory included, in addition to the director and assistant director, 3 chiefs of divisions, 9 surgeons, 2 passed assistant surgeons, 2 pharmacists, 5 special experts, 3 assistant pharmacologists, 4 chemists, 5 assistant chemists, 1 biochemist, 3 associate bacteriologists, 1 assistant bacteriologist, 1 bacteriological technician, 1 biologist, 1 associate biologist, 1 pathologist, 1 consultant pathologist, 1 consultant dermatologist, 1 artist, 16 other technical employees, 10 administrative and clerical employees, and 41 laboratory attendants and others. PHARMACISTS AND ADMINISTRATIVE ASSISTANTS At the close of the fiscal year there were on duty 35 pharmacists and 17 administrative assistants in the service. The number of employees in this class of personnel remains practically the same. The resignations of 2 pharmacists and 2 administrative assistants during the year were responsible for the decrease from 37 to 35 and 19 to 17, respectively. At the end of the fiscal year the pharmacists and administrative assistants were classed as follows: Chief pharmacists Administrative assistants, first class Administrative assistants, second class 35 5 12 BOARDS During the fiscal year 1926, 153 boards were convened for various purposes throughout the service, as follows: Twenty-two for the medical examination of detained aliens, 11 for the examination of 14656-26-20 292 PUBLIC HEALTH SERVICE commissioned officers to determine their fitness for promotion, 18 for the examination of applicants for commission in the grade of assistant surgeon in the regular corps,6 for the examination of scientific personnel for promotion, 28 for the physical examination of Coast Guard officers for promotion, 5 for the physical examination of Coast Guard warrant officers for promotion, 37 for the physical examination of applicants for cadets in the Coast Guard, 17 for the physical examination of candidates for temporary commissions and temporary warrants in the Coast Guard, 1 to examine a Coast Guard officer to determine whether he should be ordered before a retiring board, 1 for inspecting service property, 1 for inspecting sites for a quarantine station, 1 to examine a pharmacist for promotion, 1 to consider disposition of property on quarantine hulk Newark, 1 to examine site for location of a station to combine all service activities in or around New Orleans, 1 to consider a revision of the interstate quarantine regulations, 1 to consider suitability of a reservation for a hospital site, and 1 for the examination of an alien patient in the trachoma hospital at Rolla, Mo. The board appointed May 24, 1923, for the purpose of advising with the chairman of the Employees' Compensation Commission and assisting in the establishment of standards with respect to occupational diseases and claims for compensation has continued its service during the year. Opinions have been rendered by the board in 14 cases. The accompanying statement shows the total personnel by classes and activities in the service on June 30, 1926. Attention should again be invited to the fact that collaborating epidemiologists and assistant collaborating epidemiologists, under which heading 4,442 persons are listed, are but nominal appointees, consisting almost entirely of officers or employees of State, county, and local boards of health who transmit to the Public Health Service reports of communicable diseases currently gathered by those health agencies. ACCOUNTS SECTION The accounts section of the division of personnel and accounts comprises a bookkeeping unit, voucher-audit unit, transportation-audit unit, and a pay-roll audit unit. The bookkeeping unit also handles all cost-accounting records for hospitals and relief stations and records of allotments and incumbrances in connection with appropriations. As an appendix to this report there appears a tabulated statement showing appropriations, expenditures, and balances for the fiscal year 1926. Personnel of the Public Health Service, June 30, 1926 Assistant Sur- surgeon geon ., gen- 5,.eral eral at large AsAsPassed AsPassed As- sist- Sensist- Senassist- sistassist- sist- ant ant . ior Sur- ant ior Sur- ant ant ant sursur- sursur- geon sur- surgeon geon geon sur- sur- geon geon geon geon geon geon gengeneral eral At;,.,„. Act- tend6 ,',..;`, ing ''".. assist- cialist ant and sur- congeon suitant Assistant Concol- Phar. tract laboden- Inrating nii,c sattal terne rron- epiMTnel demigeon ologist BUREAU Surgeon General's office Chief clerk's office Divisions General inspection service Detailed to other offices 1 2 7 5 1 • 1 1 1 1 5 Total FIELD Coast Guard General inspection service Perry Point, Md Public-health districts Waiting orders Hospital division: Marine Hospital No. 1, Baltimore, Md Marine Hospital No. 2, Boston, Mass Marine Hospital No. 3, Buffalo, N. Y Marine Hospital No. 5, Chicago, Ill Marine Hospital No. 6, Cleveland, Ohio Marine Hospital No. 7, Detroit, Mich Marine Hospital No. 8, Evansville, Ind Marine Hospital No. 9, Fort Stanton, N. Mex Marine Hospital No. 10, Key West, Fla Marine Hospital No. 11, Louisville, Ky Marine Hospital No. 12, Memphis, Tenn Marine Hospital No. 13, Mobile, Ala Marine Hospital No. 14, New Orleans, La 4 1 1 16 1 1 2 3 10 1 , 2 3 2 1 1 2 1 1 1 1 1 1 1 1 2 aDIAIIRS Reserve Corps Regular Corps Hiavail-HEIM Medical and scientific 3 1 1 3 1 1 4 1 2 1 1 2 1 2 1 1 1 11 7 3 2 8 3 5 1 3 3 2 4 6 13 10 10 7 6 9 3 1 8 4 3 6 2 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 4 L\D Cd.,D t\D Personnel of Public Health, Service, June 30, 1926—Continued • g=• Medical and scientific Regular Corps AsAsPassed AsPassed As- sist- Sensist- Senassist- sistassist- sist- ant • ant ior Surant sur- ior Sur- ant ant sur- sur- geon ant sur- Stir- geon sur- geon sur- surgeon geon geon geon gen- geon geon geon general eral . AtAct- tending ing assist- speant cialist sur- and geon consuitant Contract den- Intal terne surgeon Assistant Sciencoltific Pharper- labo• son_ rating macist ePinel demiologist FIELD—continued Marine Hospital No. 15, Pittsburgh, Pa Marine Hospital No. 16, Portland, Me Marine Hospital No 17, Port Townsend, Wash. Marine Hospital No. 18, St. Louis, Mo Marine Hospital No. 19, San Francisco, Calif Marine Hospital No. 20, Savannah, Ga Marine Hospital No. 21, Stapleton, N Y Marine Hospital No. 22, Vineyard Haven, Mass. Marine Hospital No. 43, Ellis island, N Y Marine Hospital No.66, Carville, La Marine Hospital No. 70, Hudson St., N Y Marine Hospital No. 82, Norfolk, Va 1 1 1 2 1 4 3 1 1 1 7 3 1 2 4 4 6 6 3 2 3 5 5 14 5 1 4 12 4 2 1 19 87 20 3 2 1 1 2 1 1 1 1 2 1 1 7 3 2 1 1 1 1 2 1 5 10 1 14 5 6 1 1 1 1 2 2 7 1 1 2 Total hospitals Relief stations: Second class Third class Miscellaneous 2 5 10 13 1 Total relief stations Foreign quarantine division: Baltimore, Md Boston, Mass Ellis Island, N. Y.(immigration) El Paso, Tex Galveston, Tex Fort Monroe, Va 1 1 1 5 1 1 1 1 4 14 2 1 1 1 RDIAIIHS HITIVRH oriana Surgeon general Assistant surgeon general at large Reserve Corps Laredo, Tex Marcus Hook,Pa New Orleans, La Rosebank, N. Y San Francisco, Calif. (immigration and quarantine) San Juan, P. R Foreign ports All others 1 1 4 1 3 1 23 5 2 2 4 10 1 1 10 2 2 2 58 84 4 1 Total 12 1 3 5 1 Total Scientific research division: Hygienic laboratory _ Leprosy investigation Malaria Nutrition studies Stream pollution_ _ _ Sewage disposal Industrial hygiene and sanitation Child hygiene Morbidity statistics All others 10 1 2 2 1 3 1 2 2 2 2 2 1 1 5 3 5 1 2 1 7 4 17 3 3 3 46 10 2 1 5 2 1 1 1 2 1 Total 4,419 Sanitary reports and statistics division Venereal diseases division Miscellaneous Total 1 3 7 22 128 19 33 1 0 8 23 32 483 219 1 31 16 24 4,419 35 OFIELacI 1 3 1 2 1 aoullasVail Domestic quarantine division: San Francisco, Calif Interstate and others Trachoma Rural sanitation All others Personnel of the Public Health Service, June 30, 1926—Continued General and technical Totals Sub Grand total BUREAU Surgeon General's office Chief clerk's office Divisions General inspection service Detailed to other offices .. 3 31 121 2 30 2 2 22 5 1 Total 1 11 1 12 5 53 128 2 31 25 219 244 14 10 18 6 53 138 3 42 FIELD Coast Guard General inspection service Perry Point, Md Public-health districts Waiting orders Hospital division: Marine Hospital No. 1, Baltimore, Md Marine Hospital No. 2, Boston, Mass Marine Hospital No. 3, Buffalo, N. Y Marine Hospital No. 5, Chicago, Ill Marine Hospital No.6, Cleveland, Ohio Marine Hospital No. 7, Detroit, Mich Marine Hospital No. 8, Evansville, Ind Marine Hospital No. 9, Fort Stanton, N. Mex Marine Hospital No. 10, Key West, Fla Marine Hospital No. 11, Louisville, Ky Marine Hospital No. 12, Memphis, Tenn_ Marine Hospital No. 13, Mobile, Ala Marine Hospital No. 14, New Orleans, La Marine Hospital No. 15, Pittsburgh, Pa 22 1 1 1 1 1. 1 1 1 1 1 16 12 10 16 _11 10 5 10 4 5 5 10 34 8 1 1 1 2 1 2 2 1 3 1 2 1 1 2 1 2 1 1 1 3 1 2 3 2 2 1 . 2 4 3 9 1 6 18 13 4 6 4 4 7 6 5 2 12 1 4 2 3 15 3 55 57 19 53 27 31 15 102 11 19 20 35 103 21 25 18 18 24 14 16 7 6 4 15 10 11 35 9 83 78 36 83 47 48 22 130 16 28 28 51 163 36 108 96 54 107 61 64 29 136 20 43 38 62 198 45 HOIMIRS HIrlVaH Ofififid Laboratorians ScienAll Medi- Gen. labo- ministific Ma, other cal era! rating trative DrugDiet rine Nurse Aide teriolPilot "' Clerk emand and gist tian engigenic demi_ assi st-p ployscientech"bJ laboneer and ees tific nical ologist ant roent- ratory genology 1 Marine Hospital No. 16, Portland, Me Marine Hospital No. 17, Port Townsend, Wash Marine Hospital No. 18, St. Louis, Mo Marine Hospital No. 19, San Francisco, Calif Marine Hospital No. 20, Savannah, Ga Marine Hospital No. 21, Stapleton, N. Y Marine Hospital No. 22, Vineyard Haven, Mass Marine Hospital No. 43, Ellis Island, N. Y Marine Hospital No. 66, Carville, La Marine Hospital No. 70, Hudson St., N. Y Marine Hospital No. 82, Norfolk, Va 1 2 2 2 1 1 1 1 1 6 11 7 33 12 30 2 33 1 5 22 1 1 1 4 1 3 1 1 3 1 2 4 2 2 , 1 2 4 7 5 12 1 9 5 11 8 1 2 2 2 .2 2 18 30 25 99 31 126 7 155 256 40 80 Total hospitals Relief stations: Second class Third class Miscellaneous 3 1 1 15 9 2 • 12 Total relief stations Foreign quarantine division: Baltimore, Md Boston, Mass Ellis Island, N. Y.(immigration) El Paso, Tex Galveston, Tex Fort Monroe, Va Laredo, Tex Marcus Hook,Pa New Orleans, La Rosebank, N. Y San Francisco, Calif. (immigration and quarantine) San Juan, P. R Foreign ports All others 1 1 3 2 3 2 2 2 2 2 1 2 3 3 4 2 2 4 2 1 3 14 18 3 . 2 1 1 1 3 1 1 1 1 9 3 2 4 11 17 21 11 13 12 23 12 12 21 116 45 23 24 171 Total Domestic quarantine division: San Francisco, Calif Interstate and others Trachoma Rural sanitation All others ' Total 8 4 3 1 1 3 23 34 9 90 13 14 5 21 24 14 21 3 22 9 35 21 27 45 37 148 52 176 10 205 265 63 117 401 1,994 60 103 2 34 9 165 43 2 7 19 3 2 3 2 3 6 16 6 3 97 89 21 31 14 14 17 28 12 19 27 134 55 26 28 218 258 644 1 16 4 8 1 23 37 18 95 16 30 189 41 50 58 172 66 197 13 227 274 98 138 2,395 94 112 2 208 t:11 C 23 38 33 17 19 31 14 22 33 150 61 29 125 307 W tsd H ITI Cfi tt P:J C tt 902 24 53 22 103 17 219 Personnel of Public Health, service, June 30, /926—Continued General and technical Marine engineer 29 1 3 1 1 Clerk All Medi- Genother cal eral emand and ploy- scien- techees tifle nical 10 1 1 3 3 58 4 11 6 20 11 5 8 12 8 4 5 14 Total_ 23 1 23 17 3 . 12 351 34 21 28 29 34 38 459 Grand total 17 4 7 3 15 4 27 8 4 13 97 5 12 9 23 102 219 321 4,419 9 56 1 23 9 4 4,442 65 5 3,361 8,865 Total Sanitary reports and statistics division Venereal diseases division Miscellaneous Sub DrRUH Scientific research division: Hygienic laboratory Leprosy investigation Malaria Nutrition studies Stream pollution .Sewage disposal Industrial hygiene and sanitation Child hygiene Morbidity statistics All others Laboratorians Scienin tific Dieti- bac- , teriolPilot '`.Y.tian . genic and laboroent- ratory genology 2,315 5,504 20 13 14 26 114 9 19 12 38 4 47 21 18 39 Earwax ColAdlabo- minisrating , trative Drug" gist Nurse Aide demi- assistant ologist aDIAII5IS • Totals CHIEF CLERK'S OFFICE FORCE ON DUTY IN THE BUREAU On June 30, 1926, there were 226 departmental employees on the rolls of the bureau, including 30 detailed for duty to the Bureau of Supply of the Treasury Department. This number represented a net decrease of 8 employees during the year, with a resulting net saving of $14,060 in salary expenditures. The work of the bureau as a whole showed no decrease, and this saving in personnel was largely made possible by an increase in individual efficiency and improvements in methods of work. The average salary on June 30, 1926, was $1,679, as compared with $1,702 at the beginning of the fiscal year. PRINTING AND BINDING The total expenditure for printing and binding for the Public Health Service was $81,133.56. Of this amount, $67,983.18 was expended for the printing of publications, $9,846.86 for blank forms and records, and $3,303.52 for binding books for library and reference use, both in Washington and at field stations. The number of copies of publications printed was 1,126,299 and of blank forms 6,655,802. PUBLIC HEALTH SERVICE LIBRARY During the fiscal year 1926 the bureau library received accessions of 291 bound volumes and 300 pamphlets, making a net total on hand at the end of the year of 11,339 volumes and approximately 5,350 pamphlets. The library received regularly 160 medical and scientific journals, of which only 34 were paid subscriptions. These were circulated to the respective divisions and used in the library for reference purposes. Approximately 125 monthly and weekly bulletins from State, city, and foreign health departments were also received. The library force, while small, did a considerable amount, of research and reference work for the scientific officers and employees of the service, and also in order to furnish information in response to inquiries. In the work of the library extensive use is made of the facilities of other libraries in the city. IMPROVEMENTS AND ECONOMIES Expenditures for supplies and services for the bureau were reduced from $13,179.89 in 1925 to $10,489.02 in 1926. The work of consolidating the files of all bureau divisions into a central unit 299 300 PUBLIC HEALTH SERVICE progressed materially, and a considerable quantity of old archives and records were examined and arranged in accordance with modern filing methods. Punctuality in reporting for duty continued to improve, the cases of tardiness being 1.7 per annum per employee, as compared pith 2.3 in the previous year. The average sick leave for the year was 8.7 days per employee. BUILDINGS AND OFFICE QUARTERS The bureau now occupies space in the Butler Building and Buildings C and F,the latter two being temporary structures. The service also operates the Hygienic Laboratory, a plant of considerable extent, comprising 4 permanent buildings on a site of approximately 5 acres at Twenty-fifth and E Streets NW. It would be greatly in the interest of efficiency and economy if a suitable modern building for the accommodation of all the bureau activ,ities could be provided immediately adjacent to the present Hygienic Laboratory. NURSING, DIETETIC, AND RECONSTRUCTION SECTION During the past fiscal year the work of the nursing service has gone forward as usual with 356 nurses, 21 dietitians, and 40 aides on duty, of whom the great majority of nurses, 325, and all dietitians and aides are appointed to the hospital division. In the child hygiene section their are 3 nurses; industrial hygiene section, 2 nurses; trachoma work, 8 nurses; and rural sanitation, 5 nurses. In foreign quarantine there are assigned 2 nurses at Hoffmans Island, 2 at Gallops Island, 1 at Angel Island, and 1 for part time at New Orleans quarantine. Out of the 356 nurses 170 have left the service, but have all been replaced. This constitutes almost 50 per cent of the total number employed; of these 170, 1 died, 31 married, and 25 were released as not qualified for the service, a total of 57, leaving 113: Of this number 10 resigned to go with other Government Servic,es, 10 to accept better positions, and 14 on account of illness in family, leaving 79 who resigned, giving no adequate reason for this action. Of these conditions there may be cited as causes of dissatisfaction: 1. Quarters.—Quarters for nurses in the Public Health Service stations, while much improved, are still below the average found in other Government services and in civilian institutions. This is believed to be the most serious handicap to the nursing service. 2. Lack of promotion in pay for length of service.—This is a much discussed topic, and even a small increase in salary for each threeyear period of service would go far toward increasing the stability of the service. While the turnover is larger than in other Government services, it is in some degree offset by the fact that there is a list of nurses awaiting appointments in the service and about one-third of those who resign request reinstatement. During the year 247 inquiries and requests for applications were received; of these 76 applications were completed and sent to the Civil Service Commission and 12 were rejected. There were certified to the Public Health Service by the Civil Service Commission 276 names. There were 74 selected on papers forwarded by the Public Health Service to the Civil Service Commission, and 29 directly from civil-service certificates. The total of those appointed who failed to report was 34. From these figures it will be seen that the greater number of nurses appointed to the service were recruited by the Public Health Service. New appointments for the year were 114, reinstatements 41, and 3 additional nurses were appointed due to the increase in the number of patients. There were 30 promotions. Travel orders were written 301 302 PUBLIC HEALTH SERVICE for 236 nurses during the year, of whom 112 were furnished with transportation, 49 were appointed without expense, and 75 paid their own transportation; therefore, more than 50 per cent of those appointed traveled at no expense to the Government. All nurses who desire reinstatement are required to defray their own transportation expenses. Legislation similar to that by which the Army and Navy Corps are established becomes increasingly urgent. The passage of the retirement bill for the Army and Navy nurses is an added reason. The professional qualifications for appointment in all these services are the same, and the pay, privileges, etc., should be the same as well. The quality of work performed by nurses in the Public Health Service is as good as is found in any hospitals, Government or civilian, throughout the country, and it would be of material advantage to the bureau if this nursing service were placed on a definite legislative basis and if better quarters could be furnished. During the year the superintendent of nurses has inspected the nursing dietetic, and physiotherapy work in stations at Stapleton, Ellis Island, Hudson Street, Baltimore, Norfolk, San Francisco, Port Townsend, Chicago, St. Louis, Rolla, and Memphis. The service in these stations is excellent. In many of the stations the work is handicapped by defects in construction, lack of adequate space need for repairs etc., but in spite of these handicaps the service rendered ' from all departments compares favorably with similar the patients service in other Government or civilian institutions. There are 21 dietitians on duty in the service, and of these, 10 resigned during the past year. Of 33 aids, 7 resigned, 2 were discontinued as not meeting requirements, and 2 were discontinued on reduction of personnel; not as large a proportion as in the nursing and dietetic services, but too large for the stability which is desired. The superintendent of nurses has attended a number of nursing conferences as usual. She, has served as secretary of the nurses' advisory council of the Veterans' Bureau, of which two meetings were held, and she was reelected chairman of the section on Government nursing services of the American Nurses' Association. Various papers have been prepared for publication or for special meetings. The classes in public-health nursing in cooperation with the Instructive Visiting Nurse Association have been continued. Three classes have received a course of 16 lectures each by officers of the Public Health Service. An exhibit for the nursing service in conjunction with the regular service exhibit has been prepared for the Sesquicentennial Exposition at Philadelphia. The supervision of the emergency rest room has been, as usual, under the care of the nursing section. Follow-up of absentees without home visits has been carried on and monthly reports of illnes.5 made to the industrial hygiene section. One thousand four hundred visits to the emergency room C building have been made, an average of four and one-half visits a day during 305 working days. Of this number, 193 were employees from other Government bureaus in C and F buildings, or cases brought in from the street, which included slight injuries, accident, or illness, leaving 1,207 members of the Public Health Service who were cared for in the rest room. RECOMMENDATIONS SCIENTIFIC RESEARCH The continuation of scientific research into the causes and prevention of human disease appears to be amply justified by the advances recorded for the year of this report. Quite aside from these accomplishments, it is of value to the public to maintain an establishment where reliable and unprejudiced information concerning health matters can be secured. The continuation of this research work on an at least undiminished scale is heartily recommended. NATIONAL QUARANTINE SERVICE New quarantine stations are needed at New Orleans, La., Sabine, Tex., and San Pedro, Calif. In view of the changed conditions and the rapid growth of shipping at New Orleans, it is necessary for efficiency of service and economy of administration that the quarantine station be removed from its present location, 90 miles down the river, to a suitable site near the city. Neither Sabine nor San Pedro has any facilities whatever for the housing of persons detained because of quarantinable disease or of the personnel and paraphernalia necessary for the conduct of quarantine activities. The business of these ports, already large, is rapidly increasing, and it is imperative that adequate facilities be provided. MAINTENANCE OF MARINE HOSPITALS In my last two annual reports mention was made of the necessity for sufficient appropriations properly to fulfill the Government's obligations to its beneficiaries. It was necessary, because of insufficient funds, to reduce the average per diem cost of hospital care to a point incompatible with satisfactory treatment. The care of sick and injured persons in any hospital is subject to a certain amount of public scrutiny. If the standards furnished fall below the conventional, public criticism follows. An increase in the appropriations is necessary. New construction to replace obsolete and dilapidated buildings, to increase ward capacity, and provide housing facilities for personnel are needed, particularly at the marine hospitals in New Orleans, San Francisco, Baltimore, Buffalo, Mobile, Key West, Fort Stanton, New Mexico, and Portland, Me. Marine hospitals are also needed at Seattle and Galveston. 303 304 PUBLIC HEALTH SERVICE PERSONNEL Attention is again invited to the fact that higher standards of medical education with consequent increased cost and the greater rewards to be found in private practice are causing increased difficulty in securing and retaining the type of physician and other scientific personnel essential to the varied and difficult duties incumbent upon the Public Health Service. In addition to this need for medical officers attention is again invited to the desirability of suitable legislation for the commissioning of sanitary engineers, dental and other scientific personnel having special responsibilities and subject to change of station. The need for additional commissioned officers in the regular commissioned corps of the service has been emphasized in former annual reports. Because of the extension to European ports of the medical examination of intending immigrants, this need has been more acutely felt during the past year than ever before. Efficient handling of the work abroad demands officers experienced in immigration work and methods in this country. It also requires training in the methods of examination, particularly in respect to mental examinations. Moreover, the training of officers to replace those who have completed a tour of three years' duty abroad is essential. The diverse duties of the service afford younger officers entering the service experience which will fit them to take their turn on foreign details. At the same time the number of medical officers employed under specific appointment can be reduced and the mobility and effectiveness of the corps increased for,emergencies such as epidemics and special investigations of public-health matters. It is earnestly recommended, therefore, that authority be given to materially increase the number of commissioned officers. It is also recommended that the appropriations be so increased as to adequately recompense for professional services and thereby insure their worth. Attention has been repeatedly directed, both by congressional committees and others, to the number of public health activities now scattered throughout Government organizations whose major purpose is not public health. Pending perhaps more radical changes by the Congress, it is believed that much good might be accomplished by suitable legislation providing for the detail of personnel of the Public Health Service to such departments, bureaus, or independent establishments to perform public health functions either by direction of.the President or by request of the head of such departments to the Surgeon General. H. S. CUMMING, Surgeon General. To the honorable A. W. MELLON, Secretary of the Treasury. APPENDIX FINANCIAL STATEMENT The following is a statement of expenditures from appropriations for the Public Health Service for the fiscal year 1926: Obligations Appropriation AiTtigri- Incurred Liquidated Public Health Service proper: Salaries, office of Surgeon Gen$100,928. 35 eral, Public Health Service_ _ _ $101,560. 00 $100,928. 35 442.84 493.66 500.00 Books, Public Health Service___ Freight, transportation, etc., 20,546. 61 24,584.01 25,000.00 Public Health Service Maintenance, Hygienic Labo38,449.01 43,055. 59 43,400.00 ratory, Public Health Service_ Pay,etc., commissioned officers and pharmacists, Public 1, 125,000.00 1, 124, 143. 20 1, 103,843.01 Health Service _ Pay of acting assistant surgeons, 303,976.85 305, 154. 78 315,000. 00 Public Health Service Pay of other employees, Public 532.96 007, 1, 97 719. 007, 1, 1, 020,000. 00 Health Service Preparation and transportation Public of remains of officers, 479.57 479. 57 3,000.00 Health Service Pay of personnel and maintenance of hospitals, Public r 5,550,037. 72 5,529,213. 12 5,441, 154.93 Health Service 395,771.47 461,972. 49 470,000.00 Quarantine Service Preventing the spread of epi335,758.69 350,399.03 366,299. 30 demic diseases Preventing the spread of epi92,773,87 99, 225. 67 demic diseases, 1925 and 1926.._ 2 102,874. 29 Field investigations of public 268, 165.67 277,663.66 282,054.00 health 18, 176. 79 21, 101. 78 22, 530. 00 Interstate quarantine service.. _ _ Interstate quarantine service, 44,878. 92 48,697. 20 2 49,601. 22 1925 and 1926 Studies of rural sanitation, 71,836. 58 73,000.00 75,000.00 Public Health Service Control of biologic products, 40,826.67 44, 960. 17 45,000. 00 Public Health Service Expenses, Division of Venereal Diseases, Public Health Serv63,049. 58 65,280. 86 75,000.00 ice Marine hospitals— 2 387. 12 Baltimore, Md 2,014.99 2,014. 99 2 2, 392. 13 Savannah, Ga 2 15, 208. 26 Boston, Mass 362. 07 884. 50 2 887. 67 New Orleans, La Quarantine station, Boston, 2 3,835. 72 Mass Total, Public Health Service proper $50.82 $631.65 6.34 4,037. 40 415.99 4,606.58 344.41 20,300. 19 856. 80 1, 177.93 9,845. 22 187. 01 12, 280.03 2,520.43 88,058. 19 66,201.02 20,824.60 8,027. 51 14,640. 34 15,900.27 6,451.80 3,648.62 9,497.99 2,924.99 4,390. 34 1, 428. 22 3,818. 28 904. 02 1, 163.42 2,000.00 4, 133. 50 39.83 2,231. 28 9,719. 14 387. 12 377. 14 522.43 335, 208.26 3. 17 3,835. 72 9,694,567.43 9,580,972.60 9,350,969. 43 230,003. 17 113,594.83 355,562. 00 354, 148. 40 1,413. 60 1, 613. 00 6,047. 67 6,047.67 6,047.67 363,222. 67 361,609. 67 360, 196.07 1,413.60 1,613.00 9,942, 582. 27 9,711, 165. 50 281,416. 77 115, 207.83 Allotments from United States Veterans' Bureau: Medical and hospital services, Veterans' Bureau Salaries and expenses, Veterans' Bureau 357, 175.00 Total,Veterans'Bureau funds_ 10,057,790. 10 Grand total Outstanding Unobligated balance 1 Includes $302,554.72 reimbursement for care and treatment of Veterans' Bureau patients and miscellaneous items. 2 Balance available July 1, 1925. Carried to the surplus fund of the Treasury. 305 306 PUBLIC HEALTH SERVICE Statement showing detailed expenditures, as required by act approved March 6, 1920: Preventing the spread of epidemic diseases Obligations Purpose Allotted Incurred Liquidated staudting Unobligated balance REGULAR 1926 APPROPRIATION Trachoma prevention $28, 793.10 Payment of personnel and other expenses in connection with plague and yellow-fever prevention 187,028.87 Expenses at foreign quarantine stations and certain ones in the United States engaged in epidemic work 127,075.00 Rocky Mountain spotted-fever control, including maintenance oflaboratory at Hamilton, Mont 19,602.00 Postage for mailing epidemic reports to foreign countries 1,018.71 Vaccine and vaccine points at United States marine hospitals and relief stations 1,087.84 Unallotted balance 1,693.78 Total regular 1926 appropriation $486.04 $28,307.06 $28,307.06 176,438.79 170,592.82 $5,845.97 10, 590.08 124,780.41 116,703.72 8,076.69 2, 294. 59 18,922.78 18,554.93 367.85 679. 22 862.15 862.15 1,087.84 366,299.30 1 350,399.03 738.01 i 156. 56 349.83 1, 693.78 335,758.69 14,640.34 15,900. 27 DEFICIENCY APPROPRIATION, 1925 AND 1926 29, 100.00 28,457.12 24,668.29 3,788.83 642.88 72, 200.46 1,573.83 70,768.55 68,105.58 2,662.97 1,431.91 1, 573.83 Total definciency appropriation, 1925 and 1926 1102,874.29 99,225.67 92,773.87 6,451.80 3,648.62 Grand total 469, 173. 59 449,624.70 428,532.56 21,092.14 19,548.89 Trachoma prevention Payment of personnel and other expenses in connection with plague and yellow-fever prevention Unallotted balance I Balance available July 1, 1925. Analysis of expenditures in accordance with General Accounting Office Bulletin No. 1, of May 11, 1922: 307 PUBLIC HEALTH SERVICE Preventing the spread of epidemic diseases [Actual payments] Classification 1926 appropriation 1925 and , 1926 appropriation Total $290,630.50 $73,655.79 $364, 286. 29 01 Personal services SUPPLIES AND MATERIALS 0200 0210 0220 0230 0240 0250 0260 0280 0290 02 03 04 05 06 07 10 11 12 13 Stationery and office supplies Medical and hospital supplies Scientific and educational supplies Fuel Wearing apparel, etc Forage and supplies for animals Provisions Sundry supplies Materials Total supplies and materials Subsistence and support of persons Storage and care of vehicles Communication service Travel expenses Transportation of things Heat, light, power, and water Rents ' Repairs and alterations Miscellaneous current expenses 1,407.66 4,684.04 3,046.99 1,424.55 82.36 1, 241. 39 5,873.05 712.67 450.97 2,094.46 3,800.63 209. 11 617.91 191.30 183. 70 3,487.91 359.91 141.30 3,502. 12 8,484. 67 3,256. 10 2,042.46 273.66 1,425.09 9,360.96 1,072.58 592.27 18,923.68 11,086. 23 30,009.91 120.00 774.09 9,954.00 1,592. 78 624.43 8,601.07 35.01 1,663. 78 30.00 4.00 188. 75 4, 186.67 489.43 290.00 901.48 21. 50 641. 25 150.00 4.00 962.84 14, 140.67 2,082. 21 914.43 9,502.55 56. 51 2,305.03 1, 176. 44 609. 91 71.05 981.95 584. 49 13. 76 680. 52 1, 176.44 1,194. 40 84.81 1,662.47 EQUIPMENT 3000 3010 3020 3050 30 Automotive equipment Furniture and fixtures Educational, scientific,and recreational equipment Other equipment Total equipment Total 2,839. 35 1,278.77 4,118.12 335,758.69 92,773.87 428,532.56 308 PUBLIC HEALTH SERVICE Qu'arantine service—Expenditures by stations [Exclusive of expenditures from the appropriation "Preventing the spread of epidemic diseases"] Name of station Pay of officers and employees Maintenance $30, 369.46 975.00 1,437. 50 2,378. 50 45,902.04 7,407.00 4,805.76 9,667.00 280.00 9,908. 14 18, 596. 33 290.00 3, 540.00 5. 951.33 2,302.50 3, 159.50 15,464. 19 840.00 27,638.83 $29. 840. 57 208.75 100.80 1, 171. 29 34, 538.62 705.76 2,371.61 4, 241.74 Total CONTINENTAL QUARANTINE STATIONS Baltimore, Md Beaufort, S. C Biscayne Bay (Miami), Fla Boca Grande, Fla Boston, Mass Brownsville, Tex Brunswick, Ga Cape Fear (Southport), N. C Cedar Keys (Bronson), Fla Charleston, S. C Columbia River (Astoria), Oreg Coos Bay (North Bend),Oreg Cumberland Sound (Fernandina), Fla Delaware Bay and River (Philadelphia), Pa Delaware Breakwater (Lewes), Del Del Rio, Tex Eagle Pass, Tex Eastport, Me El Paso, Tex Eureka, Calif Fall River, Mass Fort Monroe (Norfolk), Va_ Freeport, Tex Galveston, Tex Georgetown, S. C Gulfport, Miss Hidalgo, Tex Ketchikan, Alaska Key West, Fla Lake Sabine district, Tex Laredo, Tex Marcus Hook, Pa Mobile, Ala New Orleans, La Newport, R.I New York, N. Y Ogdensburg, N Y Pascagoula, Miss Pensacola, Fla Perth Amboy, N. J Port Angeles, Wash Portland, Me Port San Luis, Calif Port Townsend, Wash Presidio, Tex Providence, R.I Reedy Island, Del Rio Grande, Tex Roma, Tex St. Andrew (Panama City), Fla St. Georges Sound (Carabelle), Fla St. Johns River (Mayport), Fla 0 St. Joseph, Fla San Diego, Calif San Francisco, Calif San Pedro, Calif Savannah, Ga Seattle, Wash Tampa Bay, Fla Terlingua, Tex Texas City, Tex Vineyard Haven, Mass Freight and miscellaneous expenses— Total continental quarantine stations 10.00 20,000.00 $60, 210.03 1, 183.75 1, 538.30 3, 549.79 80,440.66 8,112.76 7, 177. 37 13,908.74 280.00 12,692.73 22,238.71 290.00 3,617.04 24, 529. 14 2,892.05 5,256.91 18, 109. 39 840.00 31,632.97 125.50 600.00 65,872.47 2, 197.00 45, 720.69 60.00 5,965.78 4,051.00 225.00 8,419. 12 28,976. 35 23, 273. 14 72,863.66 28,436.95 59,610. 34 5.00 320,633.93 100.00 537. 50 16, 194.69 2,162.20 39.00 16,337.11 300.00 28, 193.69 4,366. 15 8,956.67 7,299. 13 7,104.88 828.25 930.00 345.00 5,709.61 440.00 17,981.99 113,986.77 16, 176. 71 20,219.73 15,686.34 19,022.06 110.00 1,080.00 10.00 20.000.00 849, 528. 18 440, 125.57 1, 289,653. 75 20,633.82 39.594.04 16,780. 33 10,438.05 10, 137. 23 1, 271.64 31,071.87 49,731. 27 18,051.97 600.00 41,624.54 1, 720.00 30,081.62 60.00 4,855.00 2,479.00 225.00 7,603. 28 24. 218.00 20,826.79 32,000.16 19,607. 59 49,235.99 213,438.47 100.00 537.50 12,435.00 875.00 13, 165.00 300.00 24, 139.41 3,570.00 7,038.33 5,968.33 7,009.00 840.00 300.00 4,528.66 210.00 13,565. 17 72,782.11 5, 808.00 14,976. 18 8,730.00 11,971.97 110.00 1,080.00 2,784. 59 3,642.38 77.04 18, 577. 81 589. 55 2,097.41 2,645. 20 3,994. 14 125.50 24, 247.93 477.00 15,639.07 1, 110.78 1, 572.00 815.84 4,758. 35 2,446. 35 40,863.50 8,829. 36 10,374. 35 5.00 107,195.46 3, 759.69 1, 287. 20 39.00 3, 172. 11 4,054. 28 796. 15 1,918.34 1, 330.80 95.88 828.25 90.00 45.00 1, 180.95 230.00 4,416. 82 41. 204.66 10,368. 71 5,243. 55 6,956. 34 7,050.09 INSULAR QUARANTINE STATIONS Territory of Hawaii Porto Rico Virgin Islands Total insular quarantine stations Total continental and insular quarantine stations 77,008.19 21,846.92 98,855. 11 926,536.37 461,972.49 1,388, 508.86 INDEX A Page 18 Absenteeism, school, with relation to endemic goiter 225 Abstracts of field reports 292 Accounts section 290 Acting assistant surgeons, number on duty Activities recommended by the advisory committee on the education of 131 sanitarians and the future of public health in the United States 291 Administrative assistants, and pharmacists, number on duty 219 Administrative headquarters, contract physicians, table showing 36 Administrative health practice 9 Agriculture Department of, cooperation with 162 ' Aircraft traffic 157 Alastrim, prevalence of Alien seamen inspected and certified at all ports in the United States and 176 Canada, table showing Alien passengers inspected and certified at all ports in the United States 172 and its dependencies, and in Canada, table showing 169-171 Aliens (see also Immigrants) 216 American College of Surgeons 12 American Public Health Association, cooperation with 263 American Social Hygiene Association 159, 166 Amoy, China, quarantine transactions at 68 Analysis, lead 68 Analysis of arsenicals 111, 203 Anthrax, prevalence of 305-308 Appendix (financial statement) 68 Arsenicals, analysis of 216 Attending specialists 290 Number on duty 8 Automobile accidents, death rates Average per diem cost of in-patient relief, United States marine hospitals, 212 1926, chart showing .- 225 Baltimore, Md., United States marine hospital Bills rendered for quarantine services at maritime stations during the fiscal 162, 163 year, 1926, table showing Biologic products: 63 Control of 3 Regulation of interstate traffic in 66 Biological significance of glutathione and cystine 32 Black tongue, studies of 291 Boards convened 138 Boca Grande, Fla., report of quarantine station Boston, Mass.: 179 Immigration station 138 Quarantine station 226 Boston (Chelsea), Mass., United States marine hospital 226 Buffalo, N. Y., United States marine hospital 300 Buildings and office quarters Bulletins: 208 c Hygienic Laboratory 207 Public health 48 Bureau of Mines, cooperation with 48 Bureau of Standards, cooperation with 9 Bureaus of the Treasury Department, cooperation with 309 310 INDEX C . Page Cairo, Ill., Relief Station No. 220 239 California, cooperation with State and local health authorities 288 Cancer: Death rates 8 Investigation of 14, 15 Study of 66, Carlsbad Cave National Monument 126. Carville, La., United States marine hospital (see Public Health Reports, vol. 41, No. 46, November 12, 1926) 238 Cases of syphilis and gonorrhea reported to State boards of health, by months, chart showing 265 Cases of venereal diseases reported to State boards of health, chart show264 ing 271 Cases of venereal disease reported to State boards of health, table showing_ Catalogue, index, medical and veterinary zoology 65 Causes of admission for discharged patients and conditions on discharge, United States marine hospitals and other relief stations, fiscal year 249, 250' 1926, table showing Causes of death in United States marine hospitals and other relief sta251, 252 tions during fiscal year 1926, table showing 46, Causes of industrial absenteeism, studies of Charts: Average per diem cost of in-patient relief, United States marine hos212 pitals, 1926 Cases of syphilis and gonorrhea reported to State boards of health, 265 by months 264 Cases of venereal diseases reported to State boards of health _ Classes of beneficiaries treated, fiscal year 1926, at Marine Hospital 237 No 43 Classes of beneficiaries treated, Marine Hospital No. 43, fiscal year 236 1925 267 Patients admitted to clinics 267 Patients discharged as noninfectious Patients of United States Public Health Service in marine hospitals 221 and relief stations Syphilis and gonorrhea, total cases reported to State boards of health 266 by months and years Total relief and physical examinations furnished from 1915 to 1926 211 to "old line" Public Health Service beneficiaries Variations according to age of respiratory diseases in families of medi21 cal officers of Army, Navy, and Public Health Service, 1924 67, 68 Chemistry, division of 226 Chicago, Ill., United States marine hospital_ 139, 147 Chicken pox, prevalence of 299 Chief clerk's office, report of 300 Buildings and quarters 299 Force on duty in the bureau 299 Improvements and economies 299 Printing and binding 299 Public Health Service Library 2 Child health, studies of Child hygiene: 41 Dental hygiene in school children 37 Girl Scout organization, cooperation with 38 Growth and development of school children 37 Mental and physical status of negro children 39 Natural illumination of classrooms, studies 38 Physical development , 40 Vision of school children Cholera: 169 Infection from shellfishing grounds 133, 156, 159, 161, 168, 169, 201 Prevalence of 10 Civil Service Commission, cooperation with Classes of beneficiaries treated, fiscal year 1925, at Marine Hospital No.43, 236 chart INDEX 311 Page Classes of beneficiaries treated, fiscal year 1926, at Marine Hospital No. 43, chart 237 Classification of out-patient treatments famished at United States marine hospitals and other relief stations, fiscal year 1926, table showing 257 Cleveland, Ohio,'United States marine hospital 227 Clinic, Hot Springs 260 Clinical information 222 Clinical studies and investigations 260 Clinical work 215 Clinics, venereal disease 265 Clonorchiasis, studies of 16 210 Coast Guard, United States Colored population, work with 263 10 Commerce, Department of, cooperation with , Commissioned medical officers, number on duty_ 289 Commissioned officers in European ports 282 Comparative results of medical examinations of applicants for visas for 191 different geographic areas, table showing Comparison of cases of principal communicable diseases and deaths, 1925, 199 table showing Conference of the Surgeon General with State and Territorial health 132 officers_ 215 Conference, international, on the health of merchant seamen 194 Congress of the Royal Institute of Public Health Consolidated annual X-ray report, marine hospitals and second-class 218 relief stations, table Consolidated clinical laboratory report, marine hospitals and second216, 217, 218 class stations, table_ 224 Construction and repair_ 137 Continental quarantine stations, table showing transactions at 291 Contract dental surgeons, number on duty 218 Contract physicians 8 Control of venereal disease.. Cooperation of Public Health Service with— 12 American Public Health Association 48 Buerau of Mines 48 Bureau of Standards 9 Bureaus of the Treasury Department 10 Civil Service Commission 9 Department of Agriculture 10 Department of Commerce 9 Department of Justice 10 Department of Labor 9 Department of State 9 Health section of the League of Nations 9 Interior Department 65 International Commission on Zoological Nomenclature 12 International Institute of Statistics 9 International Sanitary Office 12 Millbank Memorial Fund 9, 48 Other Government departments 9, 48 Post Office Department 10 State and local health and other agencies 69 State boards of health 116, State health departments and railroad water-supply supervision 120, 122 10 United States Employees' Compensation Commission 10 United States Shipping Board 10 United States Veterans' Bureau 9 War and Navy Departments 4 Cooperative rural health work 258 Cooperative work with State health departments 12 Cornell University, laboratory facilities furnished by 267 Correctional and penal institutions 312 INDEX Costs: In-patient relief, United States marine hospitals, chart showing average per diem Per diem cost of operations in marine hospital, average Crater Lake National Park Cumberland Sound, Fla., report from continental quarantine station _ _ Page 212 209 125 139 Death rates: 8 Automobile accidents 8 Cancer 8 Diabetes 8 Typhoid fever 283, 284 Decisions of the Comptroller General_ 130 Dengue fever, prevalence of 218 Dental unit 227 Detroit, Mich., United States marine hospital 8 Diabetes, death rates 2, 6, 183, 200 Diphtheria, prevalence of 158, 159 Diseases affecting the Philippine Islands Diseases: 2 Investigation of (see also Investigations and studies) 199 Prevalence of 157 Alastrim 111, 203 Anthrax 139, 147 Chicken pox 133, 156, 159, 161, 168, 169, 201 Cholera 130 Dengue fever 2, 6, 183, 200 Diphtheria 19, 148, 200, 203 Influenza 150, 154, 160 Leprosy 27, 200, 202 Malaria 147, 183, 199, 200 Measles 169 Ohara's (tularemia) 3, 200 Pellagra 133, 158, 159, 160, 165, 167, 202 Plague 200 Pneumonia 200 Poliomyelitis 5 Quarantinable 202 Relapsing fever 183 Scabies 3, 183, 200 Scarlet fever 2, 5, 6, 7, 84, 133, 139, 141, 148, 149, 150, 152, Smallpox 153, 154, 155, 157, 159, 160, 165, 167, 168, 169, 201, 202, 287, 288 63, 101-103, 202 Trachoma 201 Tuberculosis. 76 Tularemia 2,. 107, 109, 113, 115, 118, 128, 201 Typhoid fever 5, 134, 153, 154, 160, 165, 202 Typhus fever 129, 130, 134, 154, 160, 202 Yellow fever 183, 201 Whooping cough Studies of. (See Investigations.) Disinfection. (See Fumigation.) Distribution according to class of applicants for immigration visas who were medically examined at each station August 1, 1925, to June 30, 187 1926, table showing Distribution of mixed ethyl esters of chaulmoogra oil, table showing_ _ _ _ • 25 37 District of Columbia Girl Scout organization 285 Districts, public health 70 Domestic quarantine (see Interstate quarantine) 31 Drainage studies 63, 66 Drug addiction, study of , 66 Drugs for treatment of syphilis, study of INDEX 313 E Page Economies: Chief clerk's office 299 Hospital division 209 Educational pamphlets and placards purchased and reprinted by State boards of health, table showing summary of 268, 269 Educational work with newspapers and journals 262 Ellis Island, N. Y., United States marine hospital 235 El Paso, Tex.: Report from quarantine station ,. 153 Report from immigration station 179 Employees' Compensation Commission, United States 213 Cooperation with 10 Encephalitis, epidemic, study of 62 Endemic goiter and intelligence 17 Epidemiologists: Collaborating and assistant collaborating 195 Collaborating and assistant collaborating, table showing 196 Number on duty 291 European ports, medical examinations in 6, 186 Evansville, Ind., United States marine hospital 227 Examinations: Intestinal parasites for diagnosis 65 Prospective immigrants abroad 170 Physical 219 Exhibits, lantern-slide sets, and motion-picture films borrowed or purchased by State boards of health, table showing 269 Exhibits, Public Health Service at Sesquicentennial Exposition, Philadelphia 287 Expenditures (see also Financial statement): Improvements and economies 299 Printing and binding 299 Field reports, abstracts of 225 Financial statement 305-308 Fish control of mosquito production 28 Fleas, survey of_ 145-146 Force on duty in the bureau 299 Foreign and insular quarantine and immigration, report of division of.._ 133 Acquisition of the Texas quarantine system 135 Alien passengers inspected and certified at all ports in the United 176 States and its dependencies, and in Canada, table showing Alien seamen inspected and certified at all ports in the United States 176 and Canada table showing Bills rendered' for quarantine service at maritime stations during the 162, 163 showing fiscal year, 1926, table 134 Changes in quarantine procedure Comparative results of medical examinations of applicants for visas 191 for different geographic areas, table showing Distribution according to class of applicants for immigration visas who were medically examined at each station, August 1, 1925, to 187 June 30, 1926, table showing 186 European ports 170 Examination of prospective immigrants abroad 133 General prevalence of quarantinable diseases 148 Hoffman Island transactions, table showing - 136 International relations 147 Laboratory division transactions', table showing 184 Laboratory examinations, table showing 169 Medical inspection of aliens 182 Nationalities represented by aliens, table showing 134 New quarantine station at Mobile, Ala Number and percentage of applicants for immigration visas who were 188 certified for different classes of disabilities, table showing 314 INDEX Page Foreign and insular quarantine and immigration—Continued. Nuniber and percentage of immigration cases pending at the close of 190 the fiscal year, table showing Number and percentage of the total persons certified for each class of disability who were refused visas on medical grounds, table 189 showing Number and percentage of the total persons examined who were refused visas on medical certification for different classes of condi189 tions, table showing 181 Number of aliens inspected and certified, table showing Percentage distribution of persons certified for disabilities according 188 to class of condition, table showing 158 Philippine Islands, operations of the service in 157 Porto Rico, operations of the service in 133 Quarantine transactions Quarantine transactions on the Texas-Mexican border for the fiscal 153 year 1926, table showing 169 Quarantine transactions, table showing summary of 166 Report of service operations in Europe, table showing 138 Reports from continental quarantine stations 164 Reports from foreign ports 179 Reports from immigration stations 154 Reports from insular quarantine stations Results of medical examinations of applicants for immigration visas 191 for two periods and for the whole 11 months, table showing 169 Summary of quarantine transactions Summary of transactions at national (continental and insular) quar137 antine stations for the fiscal year 1926 Summary of transactions at national (continental and insular) quar137, 138 antine stations, 1926, table showing 137 Transactions at continental quarantine stations, table showing 163 Transactions at foreign ports 163 Transactions at foreign ports, table showing summary of 167 Transactions at Habana, Cuba, table showing 154 Transactions at insular quarantine stations, table showing Vaccination history and the occurrence of vermin infestation of 193 applicants for immigration visas, table showing 136 . Violation of quarantine laws 157 Virgin Islands, operations of the service in 5 ion immigrat and ne quaranti Foreign 215 seamen Foreign 227 Fort Stanton N. Mex., United States marine hospital 134 Fumigation of rags 93-94, 133-134, 138-141, 143-144, 148-151, 157, 161 Fumigation of vessels 1 Functions of the Public Health Service Galveston Tex., Relief Station No. 245 'organization, cooperation with Girl Scout Glacier National Park Goiter: Endemic, and intelligence Endemic, and physical development Endemic, and school absenteeism Endemic, in Connecticut Endemic; in Massachusetts Field studies Incidence in the United States Iodine determinations ' Potential foci of infection References Studies Government departments, cooperation with Grand Canyon National Park Ground squirrels, eradicative measures 240 37 125 17 18 18 17 17 4 19. 19 18 19 4, 17 48 124 87-88 INDEX Growth and development of school children: Oral hygiene Physical development Physical examinations Guayaquil, Ecuador, quarantine transactions at 315 Page 38 38 38 167 167 Habana, Cuba, quarantine transactions at 12 Harvard University, laboratory facilities furnished by Hawaii: 12 Laboratory facilities furnished by 154 Operations of the service in 9 Health section of the League of Nations, cooperation with 148 Hoffman Island transactions, table showing 168 Hongkong, China, quarantine transactions at Hospital division, report of: 225 Abstract of field reports 219 Administrative headquarters, contract physician, table showing Average per diem cost of in-patient relief, United States marine 212 hospitals, chart showing Causes of admission for discharged patients and condition on discharge, United States marine hospitals and other relief stations, 249-250 fiscal year 1926, table showing Causes of death in United States marine hospitals and other relief 251-252 stations, fiscal year 1926 Classes of beneficiaries treated, Marine Hospital No. 43, fiscal year 236 1925 Classes of beneficiaries treated at Marine Hospital No. 43, fiscal year 237 1926 Classification of out-patient treatments furnished at United States 257 marine hospitals and other relief stations, fiscal year 1926 222 Clinical information 215 Clinical work Consolidated annual X-ray report, marine hospitals and second218 class relief stations Consolidated clinical laboratory report, for marine hospitals and 216,217,218 second-class stations, table 218 Contract physicians 224 Construction and repair 219 Costs of out-patient relief 218 Dental unit 222 Disposition of surplus property 209 Economies 215 Foreign seamen 214 Instruction and examination of ships' officers in first aid 215 International conference on the health of merchant seamen 214 Lighthouse Service Number of days in hospitals for patients discharged during fiscal year 1926 from United States marine hospitals and other relief stations, by broad groups of conditions and class of beneficiary__ 255-256 Number of patients of each class of beneficiary discharged from United States marine hospitals and other relief stations during 253-254 fiscal year 1926, by broad groups of conditions 243 Number of patients treated annually, 1868 to 1926 Patients of United States Public Health Service in marine hospitals 221 and relief stations, chart 219 Physical examinations 222 Radio medical advice to ships at sea Relief furnished at United States marine hospitals and other relief 246-248 stations, fiscal year 1926, classified by beneficiary 210 United States Coast Guard 213 United States Employees' Compensation Commission Transactions at United States marine hospitals and other relief sta243-245 tions, fiscal year 1926 223 Transfer of surplus property, table 224 Windmill Point, proposed hospital at 14656-26-21 316 INDEX Page Hospitals, summary of needs Hygienic Laboratory: Biologic products, control of Bulletins Chemistry, division of Infectious diseases, studies of Miscellaneous Number on duty Nutritional diseases, studies of Pathology and bacteriology, division of Pharmacology, division of State boards of health, cooperation with Viruses, serums, toxins, and analogous products Zoology, division of 225 63 208 67 61 69 291 61 61 66 69 69 65 I Illustrations: 234 Ellis Island, Marine Hospital No. 43 233 Stapleton, Marine Hospital No. 21 169-171 Immigrants (see also Aliens), medical inspection of Immigration stations, report of transactions: 179 Boston, Mass 179 El Paso, Tex 180 New York, N. Y 180 Noyes, Minn 180 Philadelphia, Pa 181 Philippine Islands 182 Port Huron, Mich 182 Presidio, Tex 183 San Francisco, Calif 185 Winnipeg, Manitoba, Canada 299 Improvements, chief clerk's office 65 Index catalogue of medical and veterinary zoology 49 Industrial and other agencies, cooperation with Industrial hygiene and sanitation: 48 Government departments, cooperation with 46 Industrial absenteeism, studies of causes 49 Industrial and other agencies, cooperation with 45 Occupational diseases, studies of 43 Occupational health hazards, surveys of 47 Statistical studies 3 Studies oL 42 Tetraethyl lead, investigations of 167 Infection of rats 19, 148, 200, 203 Influenza, prevalence of 169-171 Inspection of aliens, medical 267 Institutions, correctional and penal 214 Instruction and examination of ships' officers in first aid 9 Interior, Department of, cooperation with 65 International Commission on Zoological Nomenclature, cooperation with. 12 International Health Board, facilities for study granted representatives 12 International Institute of Statistics, cooperation with 136 International relations 194 International Sanitary Conference on the Health of Merchant Seamen_ _ _ 9 International Sanitary Office, Paris, cooperation with 290 Internes, number on duty 5 Interstate carriers, safe drinking-water supplies Interstate quarantine: 70 Report of division of Activities recommended by the advisory committee on the education 131 of sanitarians and the future of public health in the United States_ Conference of the Surgeon General with State and Territorial health 132 officers 76, 77 Examination of rats, table showing 95 Financial statement, fumigation (New Orleans), table showing 104 Interstate railroad water supplies INDEX 317 Interstate quarantine—Continued. Page Interstate sanitary districts 107 Interstate travel of diseased persons, supervision of 132 Interstate vessel water supplies 106 Mosquito control along the Texas-Mexican border 129 New Orleans, outgoing quarantine, field and laboratory operations, table showing 99 Plague eradicative measures in New Orleans, La 91 Plague preventive measures, Seattle, Wash., table showing 100 Plague suppressive measures in California 70 Public health engineering abstracts, table showing 114 Railroad supplies, table showing 105 Railroad water-supply supervision, table showing summary of 111 Rural health work 128 Sanitation and medical assistance in the national parks 122 Sanitary inspection of shellfish areas 126 Trachoma eradication work 101 Typhoid-fever cases, table showing summary of 110 Vessel supplies, table showing 106 Vessel water-supply system, table showing 107 Vessel water-supply supervision, table showing summary of 110 Water supplies used by common carriers, supervision of 104 Water-supply systems on vessels supervision of 106 Yellow-fever prevention, Texas-Mexican border, table showing summary of work 131 Interstate railroad water supplies 104 Interstate spread of disease, prevention of; rural sanitation 4, 5 Interstate travel of diseased persons, supervision of_ 132 Interstate vessel water supplies 106 Investigations (see also Studies): Antidysenteric serums, standardization of 63 Black tongue 32 Cancer 12, 14, 15 Child health 2 Child hygiene 37 Clonorchiasis 16 Dental hygiene in school children 41 Epidemic encephalitis 62 Goiter 17, 19 Influenza 19 Leprosy 12, 23 Malaria control 4 49 Mental health Milk 4, 50 Nutritional diseases_ 32 3, 32 Pellagra 12 Pneumonia 15 Racial mortality from cancer in the United States 35 Rocky Mountain spotted fever 64 Scarlet-fever preparations 51 Statistical 42 Tetraethyl lead 61 Tuberculosis 62 Vaccination sequelae 3. Jacksonville, Fla., Relief Station No. 258 Johns Hopkins University, laboratory facilities furnished by Justice, Department of, cooperation with 240 12 9 Key West, Fla.: Quarantine station United States marine hospital 139 228 318 INDEX L Labor, Department of, cooperation with Laboratory division transactions, table showing Laboratory examinations table showing (See Hygienic Laboratory.) Laboratory, Hygienic. ' Laredo, Tex., report from continental quarantine station Laws and regulations: State court decisions State legislation Lead analysis League of Nations, health section Legislation and decisions, sanitary: Comptroller General's decisions Court decisions Municipal ordinances and regulations Smallpox vaccination laws, regulations, and court decisions State and Federal laws and regulations Leprosy: Clinical observations Epidemiological studies Investigation station Prevalence of Substitutions of oils Library: Hygienic Laboratory Public Health Service Lighthouse Service Los Angeles, Calif.: Plague in Relief Station No. 266 Louisville, Ky., United States marine hospital Maintenance of marine hospitals, recommendations for Malaria: Anopheline mosquitoes, studies of Drainage studies Epidemiological studies of Fish control of mosquito production Impounded waters, studies of Prevalence of Rural malaria control, studies of Screening studies Malaria control, investigations Manila, P. I.: Relief Station No. 270 Quarantine transactions Marcus Hook, Pa., quarantine station Marine hospitals and relief, division of (see Hospital division) Marine hospitals: Baltimore, Md Boston (Chelsea), Mass Buffalo, N Y Carville, La Chicago, Ill Cleveland, Ohio Detroit, Mich Ellis Island, N. Y Evansville, Ind Fort Stanton, N. Mex Key West, Fla Louisville, Ky Memphis, Tenn Mobile, Ala New Orleans, La Page 10 147 184 153 268 267 68 198 203 203 203 203 203 23 26 23 150, 154,160 25 61 299 214 70 240 229 303 29 31 27 28 30 27,200,202 28 31 4 241 158 139 209 225 226 226 238 226 227 227 234,235 227 227 228 229 229 229 230 INDEX 319 Page Marine hospitals—Continued. 239 New York City 239 Norfolk, Va 231 Pittsburgh, Pa., 231 Portland, Me 231 Port Townsend, Wash 303 Recommendations for maintenance of 231 St. Louis, Mo 232 _ San Francisco, Calif 232 Savannah, Ga 232 Stapleton, Staten Island, N. Y 233 Stapleton, illustration 235 Vineyard Haven, Mass 147, 183, 199-200 Measles, prevalence of 8 Medical and hospital relief 229 Memphis, Tenn., United States marine hospital 49 Mental health, investigations of 125 Mesa Verde National Park 4, 50 Milk, investigations 51 Milk sanitation, annual surveys of status of cities 12 Millbank Memorial Fund, cooperation with 241 Milwaukee, Wis., Relief Station No. 278 208 Miscellaneous publications Mobile, Ala.: 134 New quarantine station 229 United States marine hOspital Morbidity reports: 197 Annual State reports 197 City reports 195 Collaborating and assistant collaborating epidemiologists 198 Foreign reports 197 Mentally diseased, feeble-minded, and epileptic 197 Monthly State reports 6 Prevalence of disease 196 Telegraphic reports, weekly 52 Morbidity statistics, studies 124 Mosquito control 129 Mosquito control along the Texas-Mexican border 28 Mosquito production, fish control of 29 Mosquitoes, anopheline studies 125 Mount Rainier National Park Narcotic addiction, studies of Nationalities represented by aliens, table showing National monuments: Carlsbad Cave Pinnacles National Negro Business League, cooperation with National Park Service, assistance rendered National parks: Crater Lake Glacier Grand Canyon Mesa Verde Mount Rainier Platt Sanitation and medical assistance in Sequoia and General Grant Yellowstone Yosemite Zion National quarantine service, recommendations for National Safety Council, cooperation with National Tuberculosis Association, conferences with Negro children, mental and physical status of 2, 3 182 126 126 12 5 125 125 124 125 125 125 122 125 123 124 125 303 12 12 37 320 INDEX New Orleans: Page Fumigation of vessels 93 Laboratory operations 92 Outgoing quarantine 93 Plague eradicative measures in 91 Port sanitary regulations 94 Quarantine station 140 Rodent catch 92 United States marine hospital 230 Newspapers and journals, education work with 262 New York, N. Y.: Immigration station 180 Quarantine station 141 United States marine hospital 239 Norfolk, Va., United States marine hospital 239 Noyes, Minn., immigration station 180 Number and percentage of applicants for immigration visas who were certified for different classes of disabilities, table showing 188 Number and percentage of immigration cases pending at the close of the fiscal year, table showing 190 Number and percentage of the total persons examined who were refused visas on medical certification for different classes of conditions, table showing 189 Number and percentage of the total persons certified for each class of disability who were refused visas on medical grounds, table showing 189 Number of aliens inspected and certified, tables showing 181 Number of days in hospital for patients discharged during fiscal year 1926 from United States marine hospitals and other relief stations, by broad groups of conditions and class of beneficiary, table showing 255-256 Number of patients admitted to Kalihi Hospital from July 1, 1925, to June 30, 1926, having children in household, table showing 26 Number of patients of each class of beneficiary discharged from United States marine hospitals and other relief stations, fiscal year 1926, by broad groups of conditions, table showing 253-254 Number of patients treated annually, 1868-1926, table showing 243 Nurses' quarters 301 Nursing, dietetic and reconstruction, report of section of 301 Nutritional diseases 3, 32 Nutrition, study of 66 • 0 Oakland, Calif., plague in Occupational diseases: Occupational dermatosis Posture in industry. Occupational health hazards, surveys of: Dust studies Studies in illumination Ventilation studies Officers (see also Personnel): Commissioned medical, number on duty Reserve, number on duty Outgoing quarantine, field operations, etc., in New Orleans, table showing_ Out-patient relief, costs of Oxidation reduction Pamphlets, film showings, lectures, exhibits Parasites, intestinal, examination for diagnosis Paris, France, quarantine transactions at. Pathology and bacteriology, division of, Hygienic Laboratory Pathology, studies in Patients admitted to clinics, chart showing Patients discharged as noninfectious, chart showing Patients of United States Public Health Service in marine hospitals and relief stations, chart 86 46 45 44 45 43 289 290 99 219 67 263 65 164 61 65 267 267 221 321 Page Pellagra: 3 Investigations 200 Prevalence of 32 Studies of 148 Pensacola, Fla., quarantine station Percentage distribution of persons certified for disabilities according to 188 class of condition, table showing 66 Permeability, study of 242 Perry Point, Md., supply station Personnel (see also Personnel and accounts): 299 Force on duty in the bureau 13 Increase of 304 Recommendations for 282 Personnel and accounts, report of division of 291 Accounts section 290 Acting assistant surgeons 290 Attending specialists 291 Boards 289 Commissioned medical officers 291 Contract dental surgeons 291 Epidemiologists 291 Hygienic Laboratory 290 Internes Personnel of the Public Health Service, June 30, 1926, table show293-298 ing 291 Pharmacists and administrative assistants 285 Public health districts 290 Reserve officers Personnel of the Public Health Service, June 30, 1926, table showing__ 293-298 148 Perth Amboy, N. J., quarantine station 291 Pharmacists and administrative assistants, number on duty Pharmacology: 66 Biological significance of glutathione and cystine 66 Cancer studies 66 Drug addiction 66 Drugs for treatment of syphilis, study of 67 Miscellaneous 66 Nutritional studies 66 Permeability studies Philadelphia, Pa.: 180 Immigration station 241 Relief Station No. 305 Philippine Islands: 158, 159 Diseases affecting 158, 159 Operations of the service in 181 Report from immigration station 219-220 Physical examinations, general and special 126 Pinnacles National Monument 231 Pittsburgh, Pa., United States marine hospital Plague:, 77 Endemic 78 Epizootic 4 Eradication of bubonic, in rodents 91 Eradicative measures in New Orleans La 87 'squirrels Field operations for control of ground 95 Financial 81 Fumigation 82, 87 Ground squirrels 74 Laboratory operations in Los Angeles 92 Laboratory operations in New Orleans 90, 91 Laboratory operations in San Francisco 70 Los Angeles 88 Measures taken against rats 86 Oakland 93 Outgoing quarantine 94 Port sanitary regulations 133, 158, 159, 160, 165, 167. 202 Prevalence of • 322 INDEX Plague—Continued. Page Prevention against .151 Preventive measures, Seattle, Wash 100 Rat poisoning 80 Rat proofing _ 81, 82 Rodent catch 78 Rodent, control of 70 Sanitary inspections in San Francisco 89 Suppressive measures in California 70 Suppressive measures in cities and counties in vicinity of San Francisco Bay 87 Transportation 94 Trapping operations 78 Trapping operations in Los Angeles 78 Trapping operations in New Orleans_ 92 Wrecking operations 80 Platt National Park 125 Pneumonia: Prevalence of 200 Study of 63 Poliomyelitis, prevalence of 200 Port Arthur, Tex., Relief Station No. 309 241 Port Huron, Mich., immigration station 182 Port Townsend, Wash.: Quarantine station 148 United States marine hospital 231 Portland, Me., United States marine hospital 231 Porto Rico, operations of the service in 157 Post Office Department, cooperation with 9, 48 Presidio, Tex.: Immigration station 182 Quarantine station 154 Prevention of the interstate spread of disease; rural sanitation 4, 5 Printing and binding 299 Property, surplus, transfer of 283 Providence, R. I., quarantine station 148 Publications: Sanitary reports and statistics division 204 Scientific research division 69 Venereal-disease division 259, 261, 262 Public health bulletins 207 Public health districts 285 Public health education, section of 204 Public health engineering abstracts 114 Public Health- Reports 204 Public Health Service, functions of 1 Q Quarantinable diseases Quarantine administration Quarantine. (See also Interstate quarantine; Foreign quarantine.) Quarantine laws, violation of Quarantine procedure, changes in Quarantine service, recommendations for national Quarantine services at maritime stations, bills rendered for Quarantine stations, insular, table showing transactions Quarantine stations, reports from continental: Boca Grande, Fla Boston, Mass Cumberland Sound, Fla_ El Paso, Tex Key West, Fla Laredo, Tex Marcus Hook, Pa New Orleans La New York, N. Y , 5, 133 141 • 136 134 303 162, 163 154 138 138 139 153 139 153 139 140 141 INDEX Quarantine stations, reports from continental—Continued. Pensacola, Fla Perth Amboy, N. J Port Townsend, Wash Presidio, Tex Providence, R. I Rio Grande and Roma, Tex Sabine, Tex San Diego, Calif San Francisco, Calif , San Pedro, Calif Quarantine stations, reports from insular: Hawaii Philippine Islands Porto Rico Virgin Islands Quarantine transactions at foreign ports: Amoy, China Guayaquil, Ecuador Habana, Cuba Hongkong, China Paris, France Yokohama, Japan Quarantine transactions, table showing summary of Quarantine station, Mobile, Ala Quarantine system, Texas, acquisition of Quarters, nurses' 323 Page 148 148 148 154 148 154 149 150 150 152 154 158-159 157 157 159, 166 167 167 168 164 168 169 134 135 301 222 Radio medical advice to ships at sea 134 Rags, fumigation of 105 Railroad supplies, table showing 110, 113, 120, 122 Railroad water-supply supervision 144-145 Rat proofing of vessels Rats: 71-93, 95-98, 138, 143-146, 151, 160 Eradicative measures 167 Plague infected 76, 77 Tables showing examination of Recommendations: 303 Maintenance of marine hospitals 303 National quarantine service 304 Personnel 303 Scientific research Regulations for the government of the United States Public Health 283 Service revised 3 Regulations of interstate traffic in biologic products 202 Relapsing fever, prevalence of Relief furnished at United States marine hospitals and other relief stations, 246-248 classified by beneficiary, fiscal year 1926, table showing Relief stations: 239 Cairo, Ill 240 Galveston, Tex 240 Jacksonville, Fla 240 Los Angeles, Calif 241 Manila, P. I 241 Milwaukee, Wis 241 Philadelphia, Pa 241 Port Arthur, Tex 241 San Juan, P. R 242 San Pedro, Calif 242 Washington, D. C 264 Reporting of venereal diseases 272, Report of clinics reporting to State boards of health, table showing 273, 274, 275, 276, 277, 278 166 Report of service operations in Europe, table showing 280 Report of 33 correctional and penal institutions, 1926, table showing_ - - - 324 INDEX Page Reports: Annual State morbidity 197 City 197 Collaborating and assistant collaborating epidemiologists 195 Foreign 198 Mentally diseased, feeble-minded, and epileptic 197 Monthly State 197 Morbidity 195 Public Health 204 Telegraphic morbidity 196 Reprints from the Public Health Reports 205 Reserve officers, number on duty_ 290 Results of medical examinations of applicants for immigration visas for 191 two periods and for the whole 11 months, table showing Results of tests, Rocky Mountain spotted fever 35 Rio Grande and Roma, Tex., quarantine station 154 Rocky Mountain spotted fever: Epidemiological studies relating to distribution and incidence 36 Field investigations 35 Preparation of vaccine 34 Prevalence of 3 Results of tests 35 Study of 3, 33, 35, 61 Tests to determine effectiveness of vaccine 34 Rodents, eradication of bubonic plague in 4 Rural health work 4, 128 Sabine, Tex., quarantine station 149 St. Louis, Mo., United States marine hospital 231 San Diego, Calif., quarantine station 150 San Francisco, Calif.: 183 Immigration station 150 Quarantine station Sanitary inspections in 89 232 United States marine hospital San Juan, P. R., relief station No. 326 241 San Pedro, Calif.: 152 Quarantine station 242 Relief station No. 355 107 Sanitary districts, interstate 126 Sanitary inspection of shellfish areas 203 Sanitary legislation and decisions 195 Sanitary reports and statistics, report of division of 197 Annual State morbidity reports 197 City reports 195 Collaborating and assistant collaborating epidemiologists Comparison of cases of principal communicable diseases and deaths, 199 1925, table showing Epidemiologists, collaborating and assistant collaborating, table 196 showing 198 Foreign reports 205 Health information by radio 205 List of publications 197 Mentally diseased, feeble-minded, and epileptic 197 Monthly State reports 195 Morbidity reports 199 Prevalence of disease 203 Sanitary legislation and decisions 204 Section of public health education 196 Telegraphic morbidity reports 122 Sanitation and medical assistance in the national parks 51 Sanitation, annual surveys of milk status of cities 5 Sanitation, shellfish 232 Savannah, Ga., United States marine hospital 183 Scabies, prevalence of 3, 183, 200 Scarlet fever, prevalence of INDEX 325 Page 14 • Scientific research: Report of division of 36 Administrative health practice 14 Cancer 37 Child hygiene 16 Clonorchiasis 69 Cooperation with State boards of health 25 Distribution of mixed ethyl esters of chaulmoogra oil, table showing_ Frequencies of 13 specified symptoms in respiratory attacks of different types as recorded by medical officers of the United States Army, Navy, and Public Health Service, for cases occurring in 22 their families during 1924, table showing 17 Goiter 60 Hygienic Laboratory Incidence of respiratory attacks of different types in families of medical officers of the United States Army, Navy, and Public 21 Health Service, 1924, table showing 42 Industrial hygiene and sanitation 19 Influenza 23 Leprosy investigation station 27 Malaria 49 Mental health 50 Milk 69 Miscellaneous Number of patients admitted to Kalihi Hospital from July 1, 1925, 26 to June 30, 1926, having children in household, table showing_ 32 Nutritional diseases 303 Recommendations for 33 Rocky Mountain spotted fever 51 Statistical office 56 Stream pollution 64 Tests of biologic products, table showing 24 Thermo-anesthesia among groups of lepers, table showing Variations according to age of respiratory diseases in families of medical officers of Army, Navy, and Public Health Service, 1924, chart 21 showing 69 Viruses serums, toxins, and analogous products 31 Screening studies 239 Seamen's Church Institute Seattle, Wash., plague-preventive measures, showing water front, labo100 ratory operations, and classification of rodents, table showing 125 Sequoia and General Grant National Parks Shellfish: 126 Sanitary control of 126 Sanitary inspection of 5 111 126 Sanitation 10 Shipping Board, United States, cooperation with Sick benefit associations and medical departments of industrial establish12 ments, cooperation with 160, 166, 167, 168, 184, 192, 193, 219 Smallpox and vaccination Smallpox: 155 In California 2, 5-7, 84, 133, 139, 141, Prevalence of 148-150, 152-155, 157, 159-160, 165,167-169,201-202, 287-288 153 Prevention against 261 Social studies and investigations Specialists. (See Attending specialists.) 290 Specialists, attending, number on duty 232 Stapleton, Staten Island, N. Y., United States marine hospital 10 State and local health and other agencies, cooperation with 9 State, Department of, cooperation with 258 State health departments, cooperation with 267 State laws and regulations... State report of doses of arsphenamin (or similar product) administered, 279 table showing 270 State report of educational activities, table showing 53 Statisticll and epidemiological studies of specific diseases_ 326 INDEX Page Statistical office_ 51 Cooperation with other agencies 55 Work in association with other offices and divisions of the service__ _ 55 Statistical studies 47 Statisti6a1 summary of activities in the control of venereal diseases, table showing 280, 281 Statistics, comparable, of deaths 7 Stream pollution 56 Epidemiological study of typhoid fever 59 Experimental studies of the phenomena of natural purification 57 Field studies 56 Miscellaneous activities 59 Studies of the efficiency of water purification 58 Studies (see also Investigations): Anopheline mosquitoes 29 Antivenom 63 Biological significance of glutathione and cystine 66 Cancer 66 Causes of industrial absenteeism 46 Child health 2 Clonorchiasis 16 Diphtheria toxoid 64 Drainage 31 Drug addiction 63, 66 Drugs for treatment of syphilis 66 Dust 44 Epidemiological, relating to distribution and incidence Rocky Mountain spotted fever 36 Goiter 17 Goiter, field 4 45 Illumination Impounded waters 30 3 Industrial hygiene and sanitation 61 Infectious diseases 27 Malaria 67 Miscellaneous 52 Morbidity statistics Narcotic addiction 2, 3 39 Natural illumination of classrooms 66 Nutrition 61 Nutritional diseases 45 Occupational diseases 65 Pathology 66 Permeability 63 Pneumonia 64 Pollen extracts 3, 33, 61 Rocky Mountain spotted fever 28 Rural malaria control 31 Screening 53 Specific diseases, statistical and epidemiological 47 Statistical 56 Stream pollution 35 Tick and blood virus, Rocky Mountain spotted fever 63, 101-103 Trachoma 61 Tularaemia 63 Typhus fever 43 Ventilation 40 Vision of school children 30 Waters, impounded 129 Yellow fever 169 Summary of quarantine transactions, table showing Summary of transactions at national (continental and insular) quarantine 137, 138 stations for the fiscal year, 1926, table showing 116, 120, 121 Summary of vessel water-supply supervision 302 Superintendent of nurses, activities of 207 Supplements to the Public Health Reports • INDEX 327 Page 242 Supply station, Perry Point, Md Surgeons: 290 Acting assistant, number on duty 291 Contract dental, number on duty 222, 283 Surplus property, disposition of Surveys: 145-146 Fleas 43 Occupational health hazards Syphilis, and gonorrhea, total cases reported to State boards of health, by 266 months and years, chart showing T Tables (see also Charts): 219 Administrative headquarters, contract physicians Alien passengers inspected and certified at all ports in the United 172 States and its dependencies, and in Canada Alien seamen inspected and certified at all ports in the United States 176 and Canada 162, 163 Bills rendered for quarantine services at maritime stations 271 Cases of venereal disease reported to State boards of health Causes of admission for discharged patients and condition on discharge, United States marine hospital and other relief stations__ 249-250 Causes of death in United States marine hospitals and other relief 251-252 stations Classification of out-patient treatments furnished at United States 257 marine hospitals and other relief stations Comparative results of medical examinations of applicants for visas 191 for different geographic areas Comparison of cases of principal communicable diseases and deaths, 199 1925 Consolidated annual X-ray report, marine hospitals and second-class 218 relief stations Consolidated clinical laboratory report, marine hospitals and second216-218 class stations 103 Dispensary and hospital relief, operations, etc., of trachoma Distribution according to class of applicants for immigration visas who were medically examined at each station August 1, 1925, to 187 June 30, 1926 25 Distribution of mixed ethyl esters of chaulmoogra oil Educational pamphlets and placards purchased and reprinted by 268, 269 State boards of health 196 Epidemiologists, collaborating and assistant collaborating 76, 77 Examination of rats Exhibits, lantern-slide sets, and motion-picture films borrowed or 269 purchased by State boards of health 95 Financial statement, fumigation (plague operations in New Orleans) Frequencies of 13 specified symptoms in respiratory attacks of different types as recorded by medical officers of the United States Army, Navy, and Public Health Service, for cases occurring in their 22 families during 1924 148 Hoffman Island transactions Incidence of respiratory attacks of different types in families of medical officers of the United States Army, Navy, and Public 21 Health Service, 1924 147 Laboratory division transactions 184 Laboratory examinations 182 Nationalities represented by aliens New Orleans, outgoing quarantine, field operations, and laboratory 99 operations Number and percentage of applicants for immigration visas who 188 were certified for different classes of disabilities Number and percentage of immigration cases pending at the close 190 of the fiscal year Number and percentage of the total persons certified for each class 189 of disability who were refused visas on medical grounds 328 INDEX Tables (see also Charts)—Continued. Page Number and percentage of the total persons examined who were refused visas on medical certification for different classes of conditions 189 Number of aliens inspected and certified 181 Number of days in hospital for patients discharged from United States marine hospitals and other relief stations, by broad groups of conditions and class of beneficiary 255-256 Number of patients admitted to Kalihi Hospital from July 1, 1925, to June 30, 1926, having children in household 26 Number of patients of each class of beneficiary discharged from United States marine hospitals and other relief stations, by broad groups of conditions 253-254 Number of patients treated annually, 1868 to 1926 243 Percentage distribution of persons certified for disabilities according to class of condition 188 Personnel of the Public Health Service, June 30, 1926 293-298 Plague-preventive measures, Seattle, Wash 100 Public health engineering abstracts 114 Quarantine transactions on the Texas-Mexican border 153 Railroad supplies 105 Relief furnished at United States marine hospitals and other relief stations, classified by beneficiary 246-248 Report of clinics reporting to State boards of health 272, 273, 274, 275, 276, 277, 278 Reporting of service operations in Europe 166 Report of 33 correctional and penal institutions 280 Results of medical examinations of applicants for immigration visas for two periods and for the whole 11 months 191 States ranked according to the monthly and daily new admissions per clinic 279 States ranked according to the percentage of increase or decrease in the number of cases of venereal disease reported to State boards of health 272 State report of doses of arsphenamin(or similar product)administered_ 279 State report of educational activities 270 Statistical summary of activities in the control of venereal diseases_ _ 280, 281 Summary of quarantine transactions 169 Summary of railroad water-supply supervision 111 Summary of transactions at national (continental and insular) quarantine stations 137, 138 Summary of typhoid-fever cases 110 Summary of vessel water-supply supervision 110 Tests of biologic products 64 Thermo anesthesia among groups of lepers 24 Transactions at continental quarantine stations 137 Transactions at foreign ports, summary of 163 Transactions at Habana, Cuba 167 Transactions at insular quarantine stations 154 Transactions at United States marine hospitals and other relief stations 243-245 Transfer of surplus property 223 Vaccination history and the occurrence of vermin infestation of applicants for immigration visas 193 Vessel supplies 106, Vessel water-supply system 107 Yellow-fever prevention, Texas-Mexican border, summary of work_ _ 131 Tests of biologic products, table showing 64 Tests to determine effectiveness of vaccine Rocky Mountain spotted fever_ 34 Texas border stations, quarantine, table ' showing tranasctions_ 153 Texas quarantine system, acquisition of 135 Thermo-anesthesia among groups of lepers, table showing 24 Total relief and physical examinations furnished from 1915 to 1926 to "old line" Public Health Service beneficaries 211 INDEX 329 Page Trachoma: 103 Dispensary and hospital relief, operations, etc., tables showing 101 Eradication work 101 Eveleth, Minn 101 Knoxville, Tenn., hospital at 63, 101-103, 202 Prevalence of 101, 102 Rolla, Mo., hospital at 101 Russellville, Ark., hospital at 63 Study of 222, 283 Transfer of surplus property 223 Transfer of surplus property, table showing Tuberculosis: 201 Prevalence of 61 Study of Tularemia: 76 Prevalence of 61 Study of Typhoid fever: 7 Death rates 2, 107, 109, 113, 115, 118, 128, 201 Prevalence of 110 Table showing summary of 219 Vaccination Typhus fever: 5, 134, 153, 154, 160, 165, 202 Prevalence of 153 Prevention against 63 Study of V Vaccination: 7, 160, 166, 167, 168, 184, 192, 193, 219 Smallpox 219 Typhoid fever Vaccination history and the occurrence of vermin infestation of applicants 193 for immigration visas, table showing 62 Vaccination sequelae, study of 34 Vaccine, preparation of, Rocky Mountain spotted fever Variations according to age of respiratory diseases in families of medical 21 officers of Army, Navy, and Public Health Service, 1924, chart showing_ 258 Venereal diseases, report of division of Cases of syphilis and gonorrhea reported to State boards of health, 265 by months, chart showing Cases of venereal diseases reported to State boards of health, chart 264 showing Cases of venereal diseases reported to State boards of health, table 271 showing 260 Clinical studies and investigations 265 Clinics 258 Cooperative work with the State health departments 267 Correctional and penal institutions Educational pamphlets and placards purchased and reprinted by 268, 269 State boards of health, table showing 262 Education work with newspapers and journals Exhibits, lantern-slide sets, and motion-picture films borrowed or 269 purchased by State boards of health, table showing 263 Pamphlets, film showings, lectures, exhibits 267 Patients admitted to clinics, chart showing 267 Patients discharged as noninfectious, chart showing Report of clinics reporting to State boards of health, table showing_ _ 272, 273, 274, 275, 276, 277, 278 262 Publications 280 Report of 33 correctional and penal institutions, table showing_ 264 Reporting of venereal diseases 261 Social studies and investigations 267 State laws and regulations_ State report of doses of arsphenamin (or similar product) adminis279 tered, table showing 330 INDEX Page Venereal diseases, report of division of—Continued. 270 State report of educational activities, table showing States ranked according to the monthly and daily new admissions per clinic, table showing 279 States ranked according to the percentage of increase or decrease in the number of cases of venereal disease reported to the State boards 272 of health, table showing Statistical summary of activities in the control of venereal diseases, 280, 281 table showing Syphilis and gonorrhea, total cases reported to State boards of health 266 by months and years Work with the colored population 263 106 Vessel supplies, table showing 112, 114, 121 Vessel water supply and sanitation supervision 107 Vessel water-supply system, table showing Vessels: Fumigation of 93, 94, 133-134, 138-141, 143-144, 148-151, 157, 161 Rat proofing of 144-145 Table showing supplies 106 10 Veterans' Bureau, cooperation with 235 Vineyard Haven, Mass., United States marine hospital 136 Violation of quarantine laws 157 Virgin Islands, operations of the service in 69 Viruses, serums, toxins, and analogous products 9 War and Navy Departments, cooperation with Washington D. C., Relief Station No. 339 242 Water supplies: 5 Interstate carriers 104 Interstate railroads 106 Interstate vessels Water-supply supervision: 110-113, 120, 122 Railroads 116, 120, 122 Cooperation with State health departments 111 Table showing summary of 106, 108, 112 System on vessels 110, 112, 114, 116, 117, 120, 121 Vessels 30 Waters, impounded, studies 231, 232 Welfare activities 183, 201 Whooping cough, prevalence of 224 Windmill Point, proposed hospital at 185 Winnipeg, Canada, report from immigration station Yellow fever: 129, 130, 134, 154, 160, 202 Prevalence of 131 Prevention, Texas-Mtxican border, table showing summary of work__ 123 Yellowstone National Park 168 Yokohama, Japan, quarantine transactions at 124 Yosemite National Park Zion National Park Zoology, division of, Hygienic Laboratory 125 65
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