typhoid fever in Bowling Green for the years 1911, 1912, and 1913 has been over 99 per 100,000, this being the highest typhoid rate of any city in Kentucky, about twice the average typhoid death rate for the State, and four times as large as that of the "registration area " of the United States. That this was not a recent or temporary condition was demonstrated by the fact that for a period of 25 years, from 1886 to 1910, the average death rate from typhoid fever had been 62 per 100,000, with great variations from year to year.

In trying to account for this excessive death rate it was found that the public water supply was derived without adequate purification from a river subject at all times, and especially in rainy seasons, to sewage pollution, that the city had no proper system of sewage disposal, and that there was no properly equipped local department of health.

The public water supply and need for a sewage system had been reported upon in 1911 by Mr. Paul Hansen, former State sanitary engineer, who had pointed out the structural defects in the present water plant and indicated the necessary improvements in construction and methods of operation.

The most imminent danger to the city consisted in the entire absence of any system of sewage disposal, surface privies being in common use. Considerable time was spent in making an estimate of their number, character, care, and distribution, the conclusion being that one-third of the residences had water-closets most of which discharged into so-called "sinks"; that at least one-half of the residences having water-closets used privies also; and that every house not provided with a water-closet had a privy. Most of these privies were insanitary, the majority being in a filthy condition, with large accumulation of discharges. No municipal ordinance was in force regulating the construction, care, and cleaning of privies.

The measures which in Dr. Frost's opinion should be applied without delay for the prevention of typhoid fever in Bowling Green comprise the organization of an efficient department of health with a full-time health officer and the necessary assistants; the improvement of the water supply by more careful operation of the purification plant and preferably by structural changes; antityphoid inoculation of residents, and especially students; the regulation of privies, pending the construction of a sanitary sewerage system; and the immediate construction of a sanitary sewerage system, which was the most urgent need of the town.

Copies of the report of Dr. Frost's investigation, with the conclusions reached, were furnished to the secretary of the State Board of Health of Kentucky and the common council of the city of Bowling Green.1

REQUIREMENTS OF HEALTH ADMINISTRATION.

So far systematic studies of public-health organization and administration have been made by the service in the States of Illinois, Kansas, Maryland, Massachusetts, Minnesota, Washington, and West Virginia, and the cities of Chicago, Ill., Baltimore, Md., Toledo, Ohio, St. Joseph, Mo., Richmond, Ind., and Bowling Green, Ky.

1 See p. 115.

In addition exhaustive compilations and analyses have been made of the legislation relating to this subject.

The information thus obtained seems to justify the conclusion that the two greatest sanitary needs of the Nation at the present time are: (1) Employment of properly qualified, full-time health officers for every community; (2) appropriations sufficiently large to conduct efficient health work.

Full-time health officers. In the recent past the principle of the employment of full-time health officers has been recognized in sanitary legislation enacted in the States of Maryland, Massachusetts, New York, North Carolina, and Wisconsin, and the island of Porto Rico. Bills of the same character have also been introduced in the legislatures of the States of Indiana and Kansas.

Adequate health appropriations.-Officers of the service have time and again expressed the opinion that at least 2 per cent of the public revenue should be spent for public-health work, since from no other expenditure is so much profit ultimately derived. The studies so far made give clear indication that a great deal of progress must be made before this desideratum can be reached. In most of the States the need is not for more health laws but for coordination of those already on the statute books, grouping of direct health functions under one executive officer, and adequate funds to enforce existing legislation.

A study made by the service in 1913 (see Public Health Bulletin No. 62) showed that only the District of Columbia, Florida, Hawaii, Nevada, Pennsylvania, and Porto Rico appropriated more than 10 cents per capita for health work, and Massachusetts, Montana, and Vermont more than 5 and less than 10 cents, while not less than 12 States were approprating less than 1 cent per capita for the same purpose. A similar study shows at present the District of Columbia, Florida, Hawaii, Idaho, Nevada, Pennsylvania, and Porto Rico in the first of these classes, the States of California, Maryland, Massachusetts, Montana, New Jersey, and Vermont in the second, while the States of Arkansas, Iowa, Nebraska, New Hampshire, New Mexico, North Dakota, South Dakota, and Tennessee are still among those appropriating less than 1 cent per capita for health work.

Appropriations of more than $100,000 a year for health work are being made at the present time only by the States of California, Florida, Illinois, Maryland, Massachusetts, New Jersey, New York, and Pennsylvania, and the District of Columbia, Hawaii, and Porto

Rico.

Courses in public health. An encouraging sign of the growing belief that public-health work must be performed by properly trained experts is the establishment of courses in public health in some of the most representative educational institutions of the country, as California University, Harvard University, Massachusetts Institute of Technology, and the Universities of Michigan, New York, Pennsylvania, and Wisconsin.

COOPERATION WITH FEDERAL AND STATE GOVERNMENTAL AGENCIES.

Following the practice in previous years, the facilities of the Hygienic Laboratory were extended to a few State and local officials for purposes of instruction. Reference is made subsequently to the

use of this laboratory as a means also of instructing the officers of the service.1

The practice was followed also during the year of cooperating with a number of other governmental departments and bureaus in the conduct of investigations. Among these departments are the Indian Service, the Bureau of Mines, and the Office of Public Roads. Cooperation was also extended to the Hawaiian and Porto Rican health authorities and the authorities of certain States, including North Carolina.

COOPERATION WITH THE INDIAN SERVICE.

In a communication of September 19, 1914, the Department of the Interior inquired whether it would be possible for the Public Health Service to extend to the physicians in the Indian Service the facilities of its laboratories by making examinations of such specimens as might be submitted from time to time to aid in the diagnosis of communicable diseases. Arrangements have been made to have diagnostic examinations made for the physicians of the Indian Service at the following laboratories maintained by the Public Health Service: Hygienic Laboratory, Washington, D. C.; Seattle, Wash.; San Francisco, Cal.; Fort Stanton, N. Mex.; St. Louis, Mo.; New Orleans, La.; Chicago, Ill.

A number of examinations have been made of various specimens submitted by the Indian Service in accordance with the arrangement made.

COOPERATION WITH HAWAIIAN AUTHORITIES.

Several opportunities have been presented to cooperate with the Territorial health department under the assignment of Surg. G. W. McCoy as sanitary adviser to the governor of Hawaii.

Typhoid-fever studies. The data in the possession of the board of health on typhoid fever on Oahu were examined critically, and while work in connection with this disease was not completed it seemed worth while to make recommendations to the board of health (1) to prevent cases being reported as "paratyphoid" unless the diagnosis is supported by the results of laboratory examination, and (2) to keep convalescent and recovered cases under the control of the board so long as bacilli were being eliminated.

Water examinations.-The sanitary engineer of the board of health, Mr. W. S. Tay, was aided in carrying out a number of bacteriological examinations of water.

Soda-water plant investigations. In connection with Mr. A. W. Hansen, Territorial food commissioner, the sanitation of soda-water plants was given attention. The cleansing solutions in use were tested by laboratory methods and found deficient in bactericidal power. This is a matter of some consequence, as it is customary in Hawaii to drink soda water directly from the bottle. As it is obvious that this might afford opportunities for the transmission of disease, it was recommended that the empty bottles be treated with a solution which would kill pathogenic bacteria or be subjected to a degree of heat sufficient to destroy pathogenic organisms.

1 See p. 82.

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Laboratory diagnosis.-Aid has been given the Territorial health department in the study of diphtheria, the examination of blood for typhoid agglutination and other biological reactions, and the examination of pus, smears, etc.

The facilities of the station were placed at the disposal of the College of Hawaii for the study of the physiological properties of glucosides derived from the awa root.

Quarantine.-Acting Asst. Surg. Hollmann cared for several cases of contagious disease at the Territorial quarantine hospital at a time when it was not practicable to secure medical assistance from any of the Territorial medical officers.

COOPERATION WITH PORTO RICAN AUTHORITIES.

At the request of the governor of Porto Rico, Surg. W. W. King was detailed on September 20, 1913, for duty with the Institute of Tropical Medicine and Hygiene of Porto Rico. This detail was in addition to his duty as chief quarantine officer for Porto Rico.

The institute is an organization of the government of Porto Rico for the study of diseases of that country and climate, and is composed of physicians with special experience in such lines.

At the time Surg. King began his connection with the institute there was being organized a temporary clinic in the mountains of the interior with a view of making investigations into the diseases of the rural population, relieving their medical needs, and obtaining data and material for study later in the laboratory of the institute at San Juan. The clinic was established near the town of Utuado, a location convenient to a district of some 40,000 people. A synopsis of the operations of this clinic was published in the last annual report, page 72.

A laboratory suitable for various lines of research was installed. At first the labors of the members of the institute were governed largely by the material available, but as the work progressed and became better known the field has become broader and more diversified. The members have worked independently upon some subjects and conjointly upon others, and along most lines satisfactory advancement has been accomplished. The progress of any scientific studies, especially research work, is necessarily slow and the time since the inauguration of this laboratory is yet too short for the completion of the investigations under way. The scope of these studies is briefly discussed below.

Sprue. This genuinely tropical disease has been the subject of special study since the organization of the institute. Until the opening of the laboratory, this study was necessarily clinical, but since then particular attention has been paid to its etiology. The result of these studies as far as completed have been published in medical journals.

Filariasis. This infection and its sequelæ, acute lymphangitis and elephantiasis, are prevalent in Porto Rico, and some work has been done upon them.

Trachoma. The finding of trachoma in a rather large percentage of the patients at the Utuado clinic led to a further investigation of the disease. Begun during the early part of 1914, the work was

terminated and the results published in the Public Health Reports and issued as Reprint No. 241.

Malaria.-One member of the institute established a clinic at Barceloneta, a coast town in a district long notorious for the prevalence of malaria. Important observations were made upon the epidemiology, pathology, prophylaxis, etc., of the disease, the results of which will be published later.

Skin diseases. The diseases of the skin have always played a prominent part in the field of tropical medicine and early attracted the attention of the members of the institute. The conditions of climate, temperature, habits of the people, and other factors favor the development of parasites, hence it is not surprising that many skin affections in warm countries are found due to them, especially to those classed as fungi. The study of these organisms as causal agents of disease has recently obtained great importance, and many obscure lesions have been found to be caused by them.

Various skin diseases have been studied at the institute laboratory, such as tinea of different kinds, otomycosis, blastomycosis, eczema, pellagra, skin ulcers, etc. In most of these cases various yeasts or fungi have been found, but their identification and study has not yet been completed for publication.

In addition to the organisms found in diseased conditions various fungi appearing as spontaneous growths occurring as saprophytes have been isolated and preserved for identification and comparison. Other diseases. Various diseases and conditions of great rarity or minor importance have been touched upon as opportunity and time have permitted. There exist in Porto Rico other tropical diseases of importance which are comprehended in the program of the institute, to be taken up in the future.

CONFERENCE WITH NORTH CAROLINA AUTHORITIES RELATIVE TO MANUFACTURE OF BIOLOGIC PRODUCTS.

On request of the president of the State Board of Health of North Carolina, Passed Asst. Surg. J. P. Leake was directed to proceed on January 15, 1915, to Raleigh, N. C., for the purpose of conferring with the secretary of the North Carolina State Board of Health and the director of the State laboratory of hygiene regarding the establishment at or near Raleigh of a State laboratory to manufacture biological products.

After investigation and thorough consideration of the situation, Dr. Leake's views were submitted to the secretary of the State board of health. The plans of the board contemplated action by the legislature authorizing the manufacture of biological products for free distribution or for sale at reduced prices and making an appropriation of $15,000 for initial expenditure and an appropriation of $7,500 for annual maintenance. In Dr. Leake's opinion, this amount would permit the manufacture of only one product, which it was understood would be diphtheria antitoxin. Even then the manufacture would have to be on a scale too small to allow any profits to accrue from sales at reduced prices, and therefore no great reduction in cost would result to the public. Dr. Leake suggested that the manufacture of antitoxin should not be undertaken, in view of the requirements of