factors in the causation of these 16 cases. The water supply was the only factor common to all cases, and the seasonal occurrence of the cases seemed to point to its being a possible agent in the prevalence of the disease.

Bacteriological examinations of the water and a sanitary survey of the source of supply seemed to warrant the statement that the Florence water supply, obtained from a creek near the outer limits of the city, can not be considered safe for drinking purposes. While the pollution of this creek was unquestionably intermittent it was, however, inevitable and greatest following rainfalls.

The recommendations made by Dr. Preble for the prevention of typhoid fever in Florence embraced in the first place the immediate improvement of the public water supply by means of the installation of a temporary disinfection apparatus and the employment of a sanitary engineer to advise in regard to the most advantageous method for obtaining a permanent safe supply. Other recommendations emphasized the need of the installation of a sanitary sewerage system, the abolishment of all surface privies, sanitary supervision of the production and handling of milk, proper collection and disposal of manure and garbage, reporting of all cases of communicable diseases, bedside prophylaxis in all typhoid cases, and the organization of an efficient health department with a full-time health officer.

TYPHOID FEVER IN PRINCETON, N. J.

In response to a request of the authorities of Princeton University, New Jersey, Passed Asst. Surg. R. M. Grimm was directed to proceed to Princeton on November 24, 1914, for the purpose of assisting the chairman of the sanitary committee of the university to determine, if possible, the cause of a reported outbreak of typhoid fever.

It was found that during the week ending November 15 four cases of typhoid fever had developed in the student body, which numbered approximately 1,600 persons, while only one case had been reported from the town of Princeton during the month of October. An investigation conducted by the chairman of the sanitary committee had determined that the only common factor in the histories of the four cases was their having patronized three restaurants frequented by a large number of students. It was also found that during the athletic games in October the University grounds had been visited by thousands of persons, among whom many transient venders of eatables were present, and that each of the four cases had been away from Princeton at times which made it possible to have the infection contracted elsewhere. The sanitary committee apparently had control of the situation, since no new cases had occurred for 12 days, and it was obvious that no epidemic was imminent. Prophylactic vaccination of the students against typhoid fever had been advised by the chairman of the sanitary committee of the university, and 200 doses of this preparation were furnished for this purpose from the Hygienic Laboratory.

TYPHOID FEVER IN PORTSMOUTH, OHIO.

In connection with the investigations of the Ohio River, an intensive study of typhoid fever in Portsmouth, Ohio, begun in Octo

1 See p. 99.

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ber, 1913, by Passed Asst. Surg. L. R. Thompson, was continued until October 1, 1914, by Dr. Thompson and Asst. Surg. M. H. Neill. During this period 283 cases of typhoid fever were reported in Portsmouth, and of these all except a few which could not be located were visited and investigated by Drs. Thompson and Neill. The investigation is of interest as affording statistical data, of the kind obtainable only through an intensive study, relative to the prevalence and distribution of typhoid fever in an Ohio River city taking its public water supply from the Ohio River without purification. Since the completion of this investigation a filtration plant has been installed at Portsmouth, and it is, of course, to be expected that the conditions obtaining during the investigation no longer exist in that city. It may also be anticipated that the few remaining Ohio River cities still using raw Ohio River water will improve their water supplies within a few years, and that opportunities for a study of such such conditions as have existed in Portsmouth will become increasingly rare. The data which have been collected and compiled by Dr. Thompson and Dr. Neill are now being prepared for presentation in a separate report.

MIGRATION OF TUBERCULOUS PERSONS.

The investigations into the relation to the public health of the interstate migration of tuberculous persons, mentioned in the last annual report, were continued during the year.

Studies of this problem were conducted in the States of Arizona and Colorado by Passed Asst. Surg. A. J. Lanza for a period of eight months, beginning in April, 1914. The extent of the migration of consumptives was found by him to be almost entirely a matter of conjecture, owing to the large number who never figure in any sort of official statistics. The effects of travel upon the patients themselves ranged from practically none to a severe setback, depending upon their condition and the amount of comfort with which they traveled. It seemed to be the opinion of various charitable agencies that the number of indigent tuberculous was increasing yearly, or, at least, they gave more trouble than formerly.

The danger of the spread of infection by migratory consumptives on railroad trains is, in Dr. Lanza's opinion, probably inconsequential. While some hotels may act as spreaders of infection, according to their lack of cleanliness, cheap lodging houses present a much more serious danger in this direction. Another probable source of danger, especially to children, observed by Dr. Lanza, was in soda fountains frequented by advanced consumptives, where drinking utensils were not properly cleansed.

The conclusions reached by Dr. Lanza were to the effect that the migration of tuberculous patients into Arizona and Colorado had had some unfavorable results. The chief cause lies probably in defects in the laws which permit the indiscriminate transportation of diseased indigents and furnish no remedy to the States where these persons migrate.

The complete report of Dr. Lanza has been published in the Public Health Reports and issued as Reprint No. 283.

Other reports on similar investigations in North and South Carolina by Surg. A. D. Foster, southern California by Surg. P. M. Carrington, and New Mexico and Texas by Passed Asst. Surg. E. A. Sweet, have also been published in the Public Health Reports and issued as Reprints Nos. 265, 266, and 269.

RESULTS OF THE INVESTIGATIONS IN SEVEN STATES.

As a result of these investigations, which were carried on in the health resort towns of California, New Mexico, Arizona, Texas, Colorado, and North and South Carolina, a proper understanding of conditions obtaining in localities resorted to by the tuberculous has been arrived at. The purposes of these surveys, as outlined to the officers in charge of the work, were to determine as accurately as possible (1) the extent and direction of the migration, (2) the effect of the travel on the patients themselves, (3) the relation to health of fellow travelers and railroad employees, (4) the living conditions of tuberculous persons in their new residences, and (5) the bearing on the sanitary, social, and economic status of the communities resorted to by tuberculous persons.

Extent of migration.-From observations made by the officers engaged in the investigation it was found that on the whole the migration of the tuberculous as a class is increasing, although the percentage of deaths from tuberculosis occurring within a short period of arrival is lessening. This indicates that the educational propaganda to keep far advanced cases at home have been of benefit. In some localities, especially in North and South Carolina, certain resort towns, which formerly were frequented by the tuberculous, were found to harbor very few tuberculous, owing to the increase of tourist travel, which for economic reasons has received the encouragement of local interests, while the coming of the tuberculous has been discouraged.

Effect of migration on the tuberculous.-Ordinarily travel has a detrimental effect on the tuberculous, and in advanced stages may be dangerous. Dust, confinement, altitude, and parting from friends were found to be factors which brought about this effect. Before advising tuberculous patients in respect to change of climate physicians should accordingly take into account not only the stage of the disease, but the financial status of the patient and his disposition or ability to endure separation from family and friends. Physicians should ascertain also whether suitable accommodations are available and whether competent medical advice may be obtained in the locality to which the patient is to be sent for climatic treatment. Both of these factors are indispensable in the proper treatment of the disease.

Danger of infection to other travelers.-The danger of infection to other travelers and to employees of common carriers, while present in limited degree, is not very great.

Conditions under which the tuberculous live.-The conditions under which tuberculous persons live in the localities resorted to for change of climate, and the effects of these conditions on the progress of their disease depend very largely on the question of

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finances, influenced by education and previous habits, and whether or not the patient has had and continues to have wise medical advice. Competent medical advice would retain in their home surroundings far-advanced and hopeless cases.

Economic effect of migration.-Whether the coming of the tuberculous has been of benefit to the localities under consideration is hardly considered a debatable question. The growth of cities has been favored, industries developed, and production encouraged by the invalid class. Consumptives are engaged in practically every occupation, and the business and professional life of many cities is carried on in large part by them.

Advisability of Federal control.-The question as to the advisability of the Government taking over the maintenance and care of indigent tuberculous persons who are not citizens of the State wherein they reside has of late years frequently presented itself. After careful consideration of the question it appears that while tuberculosis is the most widespread of any disease in our country and there is need for additional hospital facilities for the care and treatment of patients, it is believed that it is the duty of the several States rather than of the Federal Government to provide these facilities, and that the future policy regarding this matter is for Congress to determine. This latter would not apply, of course, to those who are now beneficiaries of the Government. In the interest of efficient administration and to protect the public health it would seem also that it should not apply to the regular personnel of the Government itself.

OCCUPATIONAL DISEASES AND INDUSTRIAL HYGIENE.

During the past fiscal year investigations of occupational diseases and the hygiene of workers have been carried on under the direction of Surg. J. W. Schereschewsky in accordance with plans formed for this work. The headquarters for these investigations were transferred at the end of the fiscal year from Washington, D. C., to Pittsburgh, Pa.

GARMENT WORKERS IN NEW YORK CITY.

The comprehensive investigation begun in the previous fiscal year of the health of garment workers and hygienic conditions in this industry was brought to a conclusion. The persons examined belong to the cloak and suit, and dress and waist industries in New York City, which employ 49,000 and 37,000 persons, respectively, or a total of 86,000 individuals.

The investigation, which was made at the request of the joint board of sanitary control in the cloak, suit, and skirt and the dress and waist industries, met with the approval of the unions of these industries, which assisted in disseminating information as to its scope and purposes. Special offices were occupied and equipped to perform the necessary examinations.

The investigation embraced a careful physical examination of over 3,000 persons, and collateral studies of the illumination in workshops,

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effect upon the atmosphere of workrooms of the use of gas-heated irons, general sanitary conditions of workshops, and home environment of workers.

Physical examination.-One thousand females and a little over 2,000 males were examined. Practically all the males were workers in the cloak, suit, and skirt trades, while some 86 per cent of the females were engaged in the dress and waist trades. The type of physical examination made was thorough, 45 to 50 minutes being spent on each individual. Besides collecting certain social and economic data, observations were made as to height, weight, circumference of chest, abdominal circumference, vital capacity, strength of grip, evidence of protection by vaccination against smallpox, pelvic measurements (in females), the systolic and diastolic blood pressure, the pulse rate, and the percentage of hemoglobin. In addition, the present physical status was carefully gone into, due note being made of defects and diseases present. In males the urine was also examined for the presence of sugar and albumen, and in 259 instances blood specimens were obtained to be tested for the presence of syphilitic antibodies.

Defects and diseases of garment workers.-The incidence of defects and diseases was noted in the case of 3,086 workers (2,086 males and 1,000 females). As a result, there were recorded 13,457 defects and diseases of all kinds, of which 9,541 were in males and 3,916 in females. This gives an average of 4.36 defects and diseases to each individual. By reason of the practice of noting all defects and diseases many of these were of a minor character, interfering neither with health nor efficiency. On the other hand, many of them had a deleterious influence upon the subject.

The examination showed no vocational diseases peculiar to the garment worker. Nevertheless, it was evident that the effect of sedentary occupations, such as women's garment industries, was to intensify the bad effects upon health and efficiency of certain defects and diseases or to produce them in predisposed individuals. Tuberculosis was undoubtedly the most important disease among garment workers, 3.11 per cent of the males examined and 0.9 per cent of the females being found to be tuberculous. This is a rate of prevalence for males of nearly ten times that of soldiers in the United States Army. It may have been that the rate of prevalence was artificially somewhat increased because workers who suspected their condition, upon hearing of the investigation, presented themselves for examination in order to ascertain whether they were suffering from tuberculosis. On the other hand, in many instances, the subject was unaware of his condition, having been conscious only of gradual impairment of health.

Apart from tuberculosis, the most common defects and diseases among garment workers, in order of frequency for both sexes, were defective vision (69 per cent), faulty posture (50 per cent of males), chronic nose and throat affections (26.2 per cent), defective teeth (26 per cent) and pyorrhea (20 per cent), dysmenorrhea (females 20.2 per cent), hypertrophied tonsils (15.3 per cent), defective hearing (10 per cent), nervous affections (7.75 per cent).