^ijfmm. i&mtW Wimtxuii f ibatg THE GIFT OF SUjaSLJOJaJt A.X&^a&7 ^3)inr|;M^ 3777 The 4ate sl|pw5 when this volume was taken. ."-To rene^ this book co^y the call Nol ;4iid give to ' ^, -■ the librarian. '' HOME USE RULES. All Books subject to Recall. All books must be returned at end of col- lege year fqr inspec- tion' and repairs. Students must re- turn all books before leaving town. Officers Lshtiuld arrange for the return of books wanted during their absence from town. Books needed by more than one person • ^re held on the reserve list. Volumes of periodi- cals and T>f pamphlets are held in the library as much as possible. For special purpose* they are given but' for a limited time. Borrowers should not use their library privileges for thebene- fit of other pereons. Books of special valiife and gift books, when the giver wishes it, are not allowed to circulate. Readers ai^e asked to report all cases of books marked or muti- lated.^ Do not deface books by marks and writing. RC 248.R6r"'""'™™'""-"'"^^ V.I -'^ Publicatlon[sJ 3 1924 005 710 755 The original of tiiis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924005710755 [Publication No. i.I SOIL POLLUTION AS CAUSE OF Ground- Itch, Hookworm Disease (Ground-Itch Anemia), and Dirt Eating. By CH. WARDELL STILES, Ph.D., U. S. Public Health and Manne-Hospital Service: A CIRCULAR FOR USE IN SCHOOLS ISSUED BY The Rockefeller Sanitary Commission FOR THE Eradication of Hookworm Disease. WASHINGTON, D. C. 1910 V, S N >)6S, <-2- Notice to Pupils : Take this circular home and read it to your parents. Notice to the Public: Copies of this circular can be obtained free upon application to The Rockefeller Sanitary Commission for the Eradication of Hook- worm Disease, 8ii Union Trust Building, Washing- ton, D. C. Notice to the Scientific and Medical Professions: The illustrations used in this circular are taken from a U. S. Government publication, now in manuscript, in which full professional details regarding the same are given. TO SCHOOL TEACHERS If an epidemic disease, such as yellow fever, cholera, or bubonic plague, is introduced into a neighborhood, great public excitement results. The epidemic is something unusual, and it becomes the topic of general discussion. Because of the unusual disease, and the exceptional number of deaths in a comparatively short time, the community is frequently led to adopt measures that are not only unscientific and unnecessary, but they are in some cases inhumane, and they not infrequently cause, to the city or State, losses in trade, money, and property. While the epidemic is still fresh in the mem- ory of families whose homes have been invaded by it, there is con- siderable watchfulness against a possible return of the dread disease, As time goes on, the memory of the excitement, anxiety, and distress diminishes, and too often a self-satisfaction and false sense of secu- rity lead the people to be contented with conditions which would not be tolerated immediately following the epidemic. Has it ever occurred to you that the great loss of human life in this country is at present due, not to extensive epidemics, but to preventable diseases that are constantly with us? And not only to preventable diseases, but to easily preventable diseases? For in- stance, has it .ever occurred to you that in our country more people ' die in one year from tuberculosis (consumption) than have died in 114 years from yellow fever? Has it ever occurred to you that thousands of lives are needlessly sacrificed in this country every year simply because the general public is either ignorant of certain elementary principles of public hygiene or careless about these prin- ciples? Think of the fact that over 35,000 Americans die every year from typhoid fever — a preventable disease due to carelessness and filth ! It is you upon whom the country depends for training the young. The mind of the adult is largely dependent upon the training during childhood. If the child is taught that certain habits will result in sickness, and even in death, he will carry that lesson into his adult life, and when he has a voice in the government of the city or the State he will recall that lesson and insist upon laws which will stop certain objectionable customs to which, because of a lack of appre- ciation of the danger involved, the average adult of today too frequently does not give a second thought. Will you as school teachers join in a movement to reduce the unnecessarily high death-rate among innocent thousands — a death- rate due in some cases to ignorance, in other cases to carelessness? In considering this proposition, your attention is invited, not only to the importance of the subject, but also to the fact that it involves work. Short-lived enthusiasm will accomplish only short-lived good. The undertaking calls for earnest, continued, serious work, year after year. The reward for that work is not an increase in pay, but a knowledge of the important fact that you wili. save human LIFE. You will save human life just as surely as does the man who plunges into a stream to rescue a drowning child. Some of the teaching will involve a discussion of subjects not ordinarily mentioned in the school-room containing both boys and girls. But human life is at stake, and in preparing this circular we must state facts in plain English; there is no escape from this method. When delicate and unusual subjects are discussed, it is suggested that you divide the classes, boys in one class and girls in another. This can easily be done in schools with more than one teacher. If the facts stated are of such a nature that a woman feels a hesitancy in teaching them to boys, or a man feels a hesi- tancy in teaching them to girls, it would be well to call upon your local physicians, clergymen, or trained nurses to help you. You will have little or no difficulty in obtaining aid from your local physicians. That the clergymen in your neighborhood will aid you when re- quested is also a self-understood fact. Doubtless the trained ntirses will be glad to help you in this work with the girls. SOIL POLLUTION AS CAUSE OF GROUND-ITCH, HOOKWORM DISEASE (GROUND-ITCH ANEMIA), AND DIRT- EATING. All children should learn these four rules for preventing disease, namely : Rule I. Do not spit on the floor, for to do so may spread disease. Both "consumption" and diphtheria are spread in this way. Rule 2. Protect against mosquitoes. Mosquitoes spread malaria ("chills and fever," or "ague"), yellow fever, dengue fever (also known as "break-bone fever"), and elephant foot.^ Rule 3. Do not pollute the soil. Hookworm disease is spread only by soil pollution. Typhoid, dysentery, and other intestinal diseases are usually spread by soil pollution. Rule 4. Protect against flies. These carry filth and germs to the food, a'nd thus spread typhoid fever. They may spread other dis- eases, also, such as consumption, inflammation of the eyes, etc. Flies are filthy creatures and should be kept out of the house. There are many other important points in protecting against dis- ease, but these four rules are of greatest importance, especially for the Southern States. Question i. What is "soil pollution"? "Soil pollution" is the act of defiling the soil or rendering it unclean ; it also refers to the condition of the soil caused by defiling it. The word "pollution" means about the same as the words "de- filement," "uncleanness," and "impurity." Polluted soil, therefore, is soil or ground which has been defiled, or made impure or unclean, or contaminated. Usually, when we speak of "soil pollution," we mean that the ground has been made unclean by placing upon it decaying or rotting material or germs which cause disease. Question 2. What are the common methods of polluting the soil ? Suppose that a person has consumption, and that, instead of spitting into a cuspidor or spittoon, he spits on the ground ; his spit or expectoration contains little germs, which are so small that they ' Elephant foot or elephantiasis is a disease in which the foot or leg swells up so as to be much larger than it should be; it is found in warm (or tropical) climates. cannot be seen by the naked eye. These little germs are scattered on the ground, and, of course, they render the soil impure, and are likely to spread consumption to healthy people. It is chiefly be- cause of this danger of spreading consumption that we see so many signs with the words "Do not spit on the floor." Or, suppose that a person has some disease of the kidneys or of the bladder, and that, instead of passing his water into a privy, he passes it onto the ground or into a brook; he pollutes or contami- nates the ground or brook with the germs which cause his disease, and thus he may spread his sickness to other people. Or, suppose that a person has disease germs in his bowels, and that, instead of going to a privy or a water-closet, he goes into a field or the woods and stools there; he pollutes the soil, and may thus spread his sickness to other people. In today's lesson we are to study this last method of soil pollution. Question 3. Does the Bible warn against soil pollution? Yes; see Deuteronomy xxiii : 12 and 13: "12. Thou shalt have a place also without the camp, whither thou shah go forth abroad; "13. And thou shalt have a paddle upon thy weapon; and it shall be, when thou wilt ease thyself abroad, thou shalt dig therewith, and shalt turn back and cover that which cometh from thee." ■Question 4. What is hookworm disease? Many people, especially in warm climates, have in their bowels a ■small worm (see figs, i, 2) about half an inch long and about as thick as a small hair-pin. If a person has many of these worms he becomes weak and sick, and his sickness is called "hookworm disease." ( ) Pigure I. A male hookworm {$), natural size. For enlarged picture see fig- 9- Figure 2. A female hookworm ( ? ), natural size. For enlarged picture see fig. 10. Question 5. How is hookworm disease spread? A person who has hookworm disease spreads it by polluting the soil. The worms cannot multiply in the bowels, but they lay hun- dreds of minute eggs (see fig. 3), and, when the person stools, these eggs are passed in the discharges. .^ 5= '^ ^ Figure 3. A hookworm egg in process of development. At first this egg contains only i cell (see l), which later divides into 2 cells (2), each of which divides, thus forming 4 cells (3, 4, s) ; these cells keep on dividing until, some- times by the end of 8 hours, a young worm (see fig. 4) is formed. Figure 4. This shows the young worm a short time after it escapes from the eggshell. The bottle-shaped structure at the blunt end is the esophagus, or gullet, and the darker organ fol- lowing this is the intestine. This worm crawls or is scattered around on the ground. It feeds for about 8 days or more, ac- cording to conditions, storing up food and growing ; during this process it sheds its skin twice, much like a snake. Figure 5. This represents the worm after it has shed its skin the second time ; the worm remains encysted, as shown, in this skin; it now no longer takes food until it enters man. It may live just so long (s months, more or less) as it can live on the food which it has already eaten. If it becomes completely dried, it dies ; therefore it cannot be blown around in the air as dust ; prolonged solid freezing kills it. When partially dry, it is quiet, but it is very active when wet, as in dew. It can wriggle up a surface which is moist. This young worm may be swallowed, but more generally it enters through the skin. (See fig. 6.) Question 6. What happens to the eggs? In about a day, if the weather is warm, a very tiny worm (se^ fig. 4) hatches out of each one of these eggs; this worm feeds for about a week; then it stops feeding and waits (fig. 5) for a chance to enter some person. It is very active when moist, but very quiet when dry; if it becomes completely dry it dies. Question 7. How does this worm enter people? The young worm enters the body in two ways : a. If there is a heavy dew, or if it rains, or if the worm is living in a moist, shady place, the young worm is very active ; when a '^R '¥»•••■ •■'"■'J i:-V';--'. Figure 6. This shows a slice of skin as seen under the microscope. Notice how the young hookworms are crawling through the skin. This is the way ■'ground-itch" or "dew-itch" looks. (Next see fig. 7.) person walks barefooted over the ground which is polluted by the presence of this young worm, the hookworm crawls into the skin (see fig. 6). Or, b. The young worms may be swallowed, either in drinking water or with some salad or other food upon which they have crawled. Question 8. If the worm enters the skin, what does it cause? When this young worm enters the skin it causes "ground-itch," also known as "toe-itch," "foot-itch," "cow-itch," "dew-itch," or "dew-poison." Thus "ground-itch" results from soil pollution, and is the beginning of hookworm disease. On this account hookworm disease may be called "ground-itch anemia," which means that a person is pale and has pale, watery blood, caused by the hookworms which entered his skin. Question 9. How many of this class have had "ground-itch"? Question 10. Describe "ground-itch." "Ground-itch" is a disease of the skin caused by coming into con- tact with moist, polluted soil. It usually occurs on the feet, on which account it is sometimes called "foot-itch," or "tOe-itch." It is very likely to occur when there is a heavy dew on the ground, and on this account it is frequently called "dew-itch," or "dew poison." It is not caused by the dew, but by tiny worms, which are very active when moist, as when there is a heavy dew. These tiny worms enter the skin and cause a small swelling; this swelling may form into an irregular line resembling a vine. The foot itches and this itching makes a person scratch. his toes and feet. Question 11. Of what disease is ground-itch the beginning? Ground-itch is usually the beginning of hookworm disease. If a boy has only a slight attack of ground-itch he may not be very sick, but if he has frequent and severe attacks of ground-itch he may grow pale and weak, and may become quite sick. Q,uestion 12. How can ground-itch be prevented? Ground-itch can be prevented by preventing soil pollution from the discharge from the bowels. Good privies should be built; peo- ple should be taught about the danger of soil pollution and the sick- ness due to it ; they should be taught that they must stool in privies instead of on the ground; and they should be taught to clean the privies. Ground-itch can usually be prevented by wearing shoes, but the most important thing is to prevent soil pollution. II Question 13. In what part of the world does ground-itch occur? Ground-itch occurs in warm climates. Thus, in the United States, it is common south of the Potomac River. Question 14. At what age is ground-itch most common? Ground-itch is more common in children than in adults. Question 15. Why is ground-itch more common in children? Because children go barefooted more than adults. Question 16. Does ground-itch occur in all parts of the South? Ground-itch is more common in the country districts than in the cities, and it is more common in sandy districts than in clay districts. Question 17. Is ground-itch the early stage of any disease other than hookworm disease? Perhaps some cases of ground-itch develop into a peculiar disease known as Cochin-China diarrhea. Some cases of ground-itch appear not to be followed by either hookworm disease or by Cochin-China diarrhea ; these cases are not yet understood. Question 18. Why is ground-itch more common in the country districts, as on farms, than in the cities? Ground-itch is more common in the country districts than in the cities because there is less care taken in the country to prevent soil pollution than there is in the cities. In large cities the city government places long pipes under the ground ; from these large pipes smaller pipes run into the houses, and water-closets are built in the houses and connected with these smaller pipes. All of these pipes together form what is called the "sewer system," and the discharges from the body are carried far away from the houses, so that the ground around the houses is not polluted. In smaller cities and towns the houses have privies in the back yards, and, when these privies are properly built, and cleaned regularly every week, as they should be, the soil does not become polluted. ' But on the farms and in the very small towns people are not so careful to prevent soil pollution, so that ground-itch is more common. Only about 60 per cent (or 6 out of 10) of 581 farm-houses, recently examined in 5 Southern States, had privies ; on account of this lack of privies, ground-itch is very common on the farm. 12 Q.uestion 19. Why are there so few privies on the farms? Because it has only recently been discovered that ground-itch is the beginning of hookworm disease, and that this disease is common 1(1-1 '1 "- :;t^^=^c'-- Figure 7. This shows some young hookworms in an organ of the armpit (axillary gland). (Next see fig 8.) "4> Figure 8. This shows a young hookworm in the blood in the heart. (Next see fig. II.) in our country, and when our fathers and mothers went to school they were not taught how dangerous it is to pollute the soil. 13 Question 20. How does ground-itch turn into hookworm disease? The young worms crawl from the skin into the blood (figs. 7 1 to 11), and from the blood they finally reach the bowels (fig. 18) ; they form a poison which injures the body, and they suck the blood. In this way they make people weak and sick. Question 21. How does a person look when he has hookworra disease? A person with hookworm disease may have very dry hair and dry, tallow-like skin; he is pale; often he has sores or ulcers on. his shins ; his abdomen (belly) or his legs may be swollen. When children have the disease they are likely to be stunted in their growth. Question 22. How does a person feel when he has hookworm disease ? A person with hookworm disease usually says he has headaches, dizziness, buzzing in the ears, palpitation of the heart, and soreness in the pit of the stomach when you press on it ; he may be very weak, and not able to work hard, walk far, or study much ; he gets tired easily; sometimes he complains that it is hard for him to breathe; usually he does not sweat much. Question 23. Does hookworm disease make it harder to study? Yes. Although some ptipils with hookworm disease are able to learn their lessons and to stand well in school, many others are too sick to study, and they fail in their examinations and beconie "repeaters."^ Question 24. Can hookworm disease be cured? Yes. There are only a few diseases which can be cured so easily as hookworm disease. Question 25. If a person has had ground-itch and is pale, what should he do? He should ask his father or mother to take him to the family doctor (physician), and should ask the doctor whether he has hookworms. ■"A "repeater" is a pupil who spends more than one year in a grade; he "repeats" his work for the year. Figure 9. A male hookworm (known as the American Murderer— becaus( a microscope. See how its head is turned backward Figure 10, A female hookworm, very much magnified. See how its head is ti .ny people), very much magnified under an instrument known as ail is broadened into an umbrella-like organ. and how its body is filled with organs containing hundreds of eggs. i6 Q,uestion 26. Can a doctor tell whether a person has hookworms simply by looking at him? Yes, in case the person has a great many hookworms and is clearly sick from the disease. If the person is not sick enough so that the ^-^' ^^^, af K r f - ; ^■^^^ ■1 -fK Figure 11. This shows two young hookworms in the kings. The worm on the left is entering the air tubes. (Next see fig. 12.) Figure 12. We now find young hookworms (see the three spots on the top of the picture) wandering up the windpipe (trachea). (Next see fig. 13.) doctor can be sure whether the patient has hookworms, it is necessary to give to the doctor a specimen (about half an ounce) of the fresh 17 passage from the bowels; this is sent by the doctor to the State Board of Health or to the State laboratory, where it is examined to see whether it contains hookworm eggs (fig. 3). If these eggs are found, the person should be treated for hookworms. Question 27. Can these eggs be seen by the naked eye? No; they are too small to be seen by the naked eye. But when the specimen is looked at under a strong magnifying glass (called a microscope, because it aids us to see small things) the doctors can see the eggs. la^- iirt m^'^W'd Figure 13. Here we see two young hookworms in the larynx (Adam's apple). The worms pass to the intestine (bowels) and again take food and grow, shedding their skin two more times. Question 28. What is the State Board of Health? This is a committee of doctors paid by the State to prevent the spread of disease. Question 29. Is it necessary to pay for having the specimen ex- amined by the State Board of Health? No ; the examination is made free of charge. All you have to do is to give the specimen to your family doctor (physician) and ask him to have the examination made. He may, however, ask you to furnish a "mailing case" (which will cost about 15 to 25 cents) in which to send it, and he may ask you to pay the postage. rx Figure 14. Head of a hookworm, greatly magnified with a microscope. We are looking directly into the mouth and see (above) the two jaws, and in the middle of the picture we see a hollow tooth, somewhat similar to the poison- iang of a snake. Figure 15. This is the same head as shown in figure 14, but at a deeper level. The two jaws are seen above and the fang-like tooth in the middle. Figure 16. This figure shows the entrance into the esophagus or gullet, -which is guarded by four cutting blades. Figure 17. A side view of the head, greatly magnified and showing the mouth cavity (the very black portion) , into which extend the prominent f ang- Uike tooth and the sharp lancets. Question 30. Can you make A mailing case at home? It is best not to try to do so, as the Post Office laws are very strict. Either buy a mailing case or write to the State Board of Health to send you one. Question 31. What should be sent with the specimen? Care must be taken to write on a paper the name, age, sex, and race (white or negro) of the person from whom the specimen comes, and also the name and address of the family physician, and to send this paper (but no other writing) in the mailing case. Figure 18. This shows the head of a hookworm as the parasite is feeding, attached to the wall of the bowels. Question 32. If a person has hookworms, should he try to doctor himself? NO. He should be doctored by his family physician, as the size of the dose of medicine depends upon the patient's age and condition, and especially upon the condition of his heart. Q.uestion 33. Is it a good plan to take "patent" or secret medi- cines for hookworms? NO. Much harm may be done by taking secret and "patent" medicines, especially those advertised as "sure cures." It is always best to go to the family physician, who can study the patient and can decide what medicine and how much of it should be used. 20 Question 34. Suppose the family physician laughs when asked if you have hookworm disease, and tells you that there is no such sickness? No doctor who is fit to be our family physician will do that. If any doctor does do that, it is time for us to select another. Figure 19. Side view of the umbrella-like expansion of the tail of the male hookworm, supported by muscular rays, similar to the ribs of an umbrella. The first worm ever described as belonging to the hookworm group happened to have these rays bent like hooks, and they were first thought to be hooks. This is the origin of the name "hookworm." Question 35. For what is hookworm disease frequently mistaken? For malaria. Many cases called "pernicious or chronic malaria" are in reality cases of hookworm disease. 21 Question 36. If hookworm disease remains untreated, what may result? A person with severe hookworm disease may become a "dirt- eater" in case he is not treated. Many persons die as a result of the infection. Some persons remain weak and sickly for years with- out knowing the cause; their strength (vitality) is reduced and if they are taken sick from some other disease, such as consumption or pneumonia, they are more liable to die than if they were not weakened by the hookworms. Some persons do not suffer any, but they may spread the disease to other people ; such persons are called "carriers." Figure 20. View of the umbrella-like expansion, spread out fiat and sliow- jng the arrangement of the "rays." Question 37. Does a person ever outgrow hookworm disease? Yes. The worms may live certainly for six and a half years and probably for ten or twelve years. If no new infection occurs, the patient will gradually improve in condition as the worms die. Question 38. How common is hookworm disease? Its frequency varies in different places. In some schools five to nine pupils out of every ten have the worms. In the cotton mills probably one person out of every four is infected. 22 Question 39. Is the paleness of the cotton-mill people due to hookworms? Yes, as a rule. Question 40. What is a dirt-eater? ; A dirt-eater is a person who has an unnatural appetite, and on this account eats clay, sand, plaster, soot, wood, cloth, or other things not intended for food. Figures 21 and 22. Ventral view (fig. 21) and side view (fig. 22) of the tail of a female hookworm. Question 41. Is dirt-eating the cause of hookworm disease? It is the result of the disease, not the cause. Question 42. Can dirt-eating be cured? Yes, very easily; by curing hookworm disease. 23 <3uestion 43. Can dirt-eating be prevented? Yes, very easily ; by preventing soil pollution and thus preventing ground-itch and hookworm disease. •Question 44. How can hookworm disease be prevented? By building good privies and keeping them clean. Not only should every house have a good privy or closet, but churches and ■■schools also should be provided with them. ^i*.!>i-_itS Figure 23. This is an extremely poor privy, from which soil pollution is ■being spread by chickens and swine. This is an altogether too frequent sight ■on our farms. Flies can breed in the filth and carry it, with disease germs, to the food. No farm with a privy of this kind should be permitted to sell milk. ■Question 45. Is there a privy in your yard? Question 46. Is there a privy at your school? 24 Question 47. Is there a privy at your church? Question 48. How should a privy be built? There should be a pail, or a barrel, or a tub, or a water-tight box under the seat (fig. 25), and the privy should be closed in back so that chickens, hogs, and dogs cannot reach the discharges. Figure 24. This is the usual style of privy found on farms and in villages. Soil pollution is spreading. Flies breed here and spread disease. Not only- can hookworms spread from such a privy, but typhoid fever and other diseases- may spread from it. No farm with a privy of this kind should be permitted to sell milk. 25 Question 49. How can flies be kept away from the tub? By pouring some fluid known as disinfectant^ into the tub. Or Figure 25. This shows a sanitary privy, designed to prevent the spread of •disease. If a pri\-y of this type were built on every farm and in every yard in villages, and if this privy were used by all persons, typhoid fever, hookworm •disease, and various other jnaladies would almost or entirely disappear. ' For parents : Such as I part of compound solution of cresol (U. S. P.) to 19 parts of water ; ordinary sheep dip also may be used. 26 some water may be placed in the tub and a cupful of crude oiP may- be poured on the water. • Question 50. Why is it dangerous for flies to visit privies? Because flies may go from the privy to the house and carry filtb and the germs of disease to the sugar, butter, bread, meat, and other food. Figure 26. A sanitary privy very similar to that shown in figure 25. Let every school boy whose home is not supplied with a water-closet see that his house has a sanitary privy. ' For parents : Kerosene oil will answer the purpose. <3uestion 51. Is it dangerous to use the human discharges for fertilizer ? It is very dangerous to health to take fresh human discharges from a privy and use the material as fertilizer. Such material is very liable to spread disease. This is especially the case in warm •climates. Some villages have "septic tanks" in which the discharges are kept for a number of hours and allowed to ferment and to become fluid. But even then they may contain disease germs, and it is best not to use them as fertilizer or carelessly dispose of them unless they are disinfected. If discharges from such tanks are used as fertilizer, it is best not to put them on fields used for growing vege- tables which are not cooked before being eaten — as celery, etc. ■Question 52. How often ought a privy to be cleaned? Once or twice a week, as a rule. Then a fresh layer of sand or ■dirt should be put into the pail, box, or tub. ■Question 53. What should be done -with the discharges? They should be buried not less than two feet deep, down hill from and certainly not nearer than 300 feet to any well or spring. Or they should be burned. Or they should be put into a pit, protected against flies, and here permitted to ferment. •Question 54. Is it safe to thro-w the discharges on the manure pile? No ; that is very, very dangerous, because of the danger of spread- ing disease to people (especially by flies, which breed in the manure) as well as to cattle and hogs. Question 55. What disease may be spread to cattle and hogs from human discharges? If a person has certain tapeworms, and cattle or hogs eat the •discharges from that person, these animals contract diseases known --as "beef measles" and "hog measles." If the meat of such animals is eaten people catch tapeworms. THE ROCKEFELLER SANITARY COMMISSION FOR THE ERADICATION OF HOOKWORM DISEASE FIRST ANNUAL REPORT OF THE SCIENTIFIC SECRETARY FOR THE YEAR ENDING JANUARY 25, 1911 OFFICES OF THE COMMISSION WASHINGTON, D. C. 1911 1%\z hi- WASHINGTON, D. C. PRESS OF JUDD & DETWEILER, INC. 191 1 FIRST ANNUAL REPORT OF THE SCIENTIFIC SECRETARY OF THB ROCKEFELLER SANITARY COMMISSION FOR THE • YEAR ENDING JANUARY 25, 1911. Herewith I have the honor to submit a general report covering the time from the date of the organization of the Commission to January 25, 191 1. In my work this past year, Surgeon-General Wyman has supported me in every way that he could possibly do so legally. I have in fact continued the same work that I have been doing for eight years past, but more intensively, due to combining the advantages of Scientific Secretary to this Commission and Professor of Zoology of the Public Health and Marine Hospital Service. Addresses and clinics. — Since the organization of the Commission I have attended a number of medical meetings in different States, and have taken advantage of these trips to give addresses before various non-medical, especially edu- cational, organizations. In all I have given 122 addresses and clinics. The traveling expenses involved in 87 of these have been paid by the Commission. The distribution of the addresses by States and organizations is seen from the fol- lowing table : THE ROCKEFELLER SANITARY COMMISSION EOR •3;e;s joj idox 00 CO 1 « V B o 'snoauEiiaosiM : :3 • M W ; j COM ■* ■sqniD • M • l-i • ^H* ; - w n ■* 3;E^S4»jniJOXBDOi;BM M ' M • "«" 1 M CO •* 'sdOnsipnE OH^ind • M l-l ^ M g" M a V "b u d s a o 1 ■siooiiDS aaqio * N 1 M M CO •BXOOqOS IBIUJOljI to 1 M M to fO ■o •saijis w M c 1 1 o It c 1 O s ft 'S s E 'c D CO u; 4 a> c a CO 1 I § 01 o 3 o a Pi 1 S2 o 1 7 = % THE ERADICATION Of HOOKWORM DISEASE. 5 Lantern slides. — Lantern slides illustrating the anatomy and life history of hookworms, the insanitary conditions under which the disease spreads, the appearance of hook- worm patients, the geographic distribution of the disease, etc., have been prepared. Nine hundred and sixty-eight such slides have been distributed to various State boards of health, and several sets of nearly 60 slides each are kept in stock to loan to medical societies, universities, clubs, teach- ers' associations, etc. Microscopic diagnosis. — Before the various State labora- tories were equipped for the microscopic diagnosis of hook- worm disease, it was necessary for me to make a large number of microscopic examinations for practicing physi- cians. At present, however, the State facilities for carrying on the work have so increased that I am being gradually relieved of this routine. As a general proposition it seems much better that the State boards should do this work, but I am always at their service in time of emergency. Correspondence. — ^The fact that the forces of the State boards of health have been increased has naturally resulted in a gradual decrease in my routine correspondence. This last year, however, the correspondence with physicians has been rather extensive. Inspections. — During the early years of the hookworm work in this country, it was necessary for me to make in- spections of schools, etc., in order to determine the geo- graphic distribution and frequency of hookworm suspects. At present, however, it seems that this work can, at least for the most part, best be left to the State boards of health. Publications. — Since the organization of the Commission, the following articles on hookworm disease by the Scientific Secretary have been published, and several more are now in press or in manuscript: StieES, C. W. : 1909W. Hookworm disease in its relation to the negro. [Reprint of Pub. Health Rep., U. S. Pub. Health and Mar.- 6 THE ROCKEFELLER SANITARY COMMISSION FOR Hosp. Serv., Wash., v. 24(31), July 30, pp. 1083-1089.] < Indianapolis M. J., v. 12(11), Nov., pp. 482-486. 19090. Idem H ^ o M-3 .a j3 j3 «j .g 26 THE ROCKEFELLER SANITARY COMMISSION FOR S I c O -* o m^ c . ri S^ 5 8^88 ■tJ tOt^ ^-^ 1- 00 H ■XJ £h (U TS "cO ■ o o o o • o ca o ii :8 88^ :8 to a o a^8 w CO V4 1) Pn T3 o o o -^ O lO ■* • y ro O N O 'X) O • (U cOTt 00 O ^O N - IH CO t-T oo" n O tJ 'b< V o CI M iriONN OMO^O a 2 .2 g "3 . M b t^CO O CI O ■M OOOt^OcfjOQlOO CO CO lO o^ t--. -^ W O^ O^ '3 (2 i-T ■<;? m" N -^ cT w' o" H o MH ° r^-U * * mber lersoni amine ctOioOMCiOioO 1^ lo r^. o covo o lo o (N Nl>.0 cOt-< CT<00 1-1 W t^ioO^cOTj-rOiO M CO « 3 P.M Z S '^H er s or lies ined * O ■ .O o O O Ti- o - lo ■ V r^ a^ o \o o uiiib farm fami xami • "^ • CI -^ CO « lO lO hT cT Z <" M-l ° ^-c' mber chooli specie * 4< M ^O CO Os CO lOVO O cO'^"^ r^iocoM coo M M C^ M M CO £ ■" a z -^ • • tS oj : ;d a ii CO cj 'H- 2 2 (u" a a. CO d cu ■= ffl "S o O iS .2 < c a > ) THE ERADICATION OE HOOKWORM DISEASE. 27 T3 a o a a o a, "J 3 to ° ^3 • t-t CO M . rt.t! o o vns >T3 til -y ■ a M 5 .ii >1 o > ^ CO C3 U Cii . CO c« a >i-S > ^ c« M a M > --a ° CO " ° « t? i 5 O o ^^ p '/I ° S o a ij •5 cU o.S a >, c« tl o s d) .1-1 rt d rr* m -^ ^ o o *^ o o a M 3 CO (U 9 o o M 0) u •-SO ■4-1 (U J3 1- n " a U ^ '°^ 3 -CO rt T300 CO ■ .g t.^-^- ■§ & 2 tl o o^ >^-g o.g hh 3 ^ oj ^<5 CO O >,to" n CD r- 3 ;z! 9 o 'd CO -2 <" S t>,S ° ^ c« CO *; 2 CO OJ f^ CO fe 3 n; CO £ o > jj n"- a as- o jq c: •rM >> to T! 3 H CO 1-1 m .14 >^ U > CO M Cii «. 11 >, Tl & r] " ^2. OP^O ^.s>; ID "^3 eg CO f^ 01 VO 00 00 00 s 00 Per livi cou (30 M O CO CN O ^'cso'vo" lO O "* y3 t^ CN o Siz; 3 O m 3 'So 28 THE ROCKEFEIvLER SANITARY COMMISSION FOR 8- ■I -^ I a o u O 0) 13 3 en's O o 3 -e I a s s S-2 Sh.2« O en CO O 4J ; CD O ■- o -M ^ ■ S'S o 1) 1 o o-S M M a o 3 s t3 a -B o a a ►S& o 5.2.2 SI'S is ^ •S 3ti Mbca t, c (u Ph ■J^ .w CO ffl S K . QubOO 2 O -"is o O _^ O di (U a . en O « . M i~ O o ^ a. OJ Oh O +j 0) O « J3 u O t3 O fO O ro O ^00 lO n M CO CO M M t^ O VO 00 o ^ M Ti- r^ CO w N W M o o o o o o o o o o o o o o o S cU a " -si .3 ca'5 a o =15 ,a * O 10 CD (N o o o o o o a s « J3 ^ 1 1 I w The EftAMCATlON OF HOOKWORM DISEASE. 29 .^ I I a o ^ ^ I to e ho ■iJ • 1 >^ u ^ ^ Eh ^ K? O. ,s P'-" •- CO Z "A timated rnber of lersons ched by these ictures. 000000000 a 000000000 3 0^ q o_^ q 3 CO '-' W CO 10 M .=1 " 3 P< ffl _5i be 3 •4- u . oi • * * M IsS WOO "-iTd-O lOlOlO H 10 10 r-^ »n i>.vo vo (N M W M IN a^-a ^z; cii ^ B^ * * 0-:^ oioooo -i-t 3 CO oflooioooo tOyiJ vo lOvO tOOO 13 a a ■tH M ' a TJ 11 * (U -d- . .00 . . ja II O^eU O'-'^ CO 4J ON ^^ M ^ ^ ' "o l-( ^° j3 •3 ca 1 i r^oooooop . ,a 4-" lOOOOOOioS^^ , fo ^ w ^ CO inoo CO > ^ " w 1 I+H ° M Oj * SS5 t^ cs . C3^ ■ i-^ r^ W • r-l ■ 11^ 3 i; a CO 10 ■ 0\\n • ^ -^ aS 1 in C ^ F- i a § c o t^ c n V *o 1 ^ 1 5? >, •a « c «• ii *■ 3 , > 1 ? 1 - 1 o ir * ^ ARK. N. ~T Mississippi. (■ TENN . (■ pnXJSVrcH [BENTON ■^ IpBENTlS T IPPAH I Q PANOLA JLAFAVETTEl. ^ \ ' pONTOTOq A ATE AVETI lONB o ■^ UEFLORO ■SARROUU^^jjgT^^vi' WuNFl-.' '^ ^ ' HoT WASHlNjrpil JSHARJ 7?^ /attala] o ,-WlNST0f4| o 1^1^ ^ > |i;aTir|0ASPEB|l-tABKE iJEFrtRSON COPIAH o O O 1° lolo 1 o 1 o fWILMNSON o AMITE ALA. IiamarI MARIOM 1 r— — I I , .1 - _ ~ |pEARU_R!ii2i Q LA. fflabsms. TENNESSEE MISS e NOKRIS FETEftS CO., WASHIHOTON, D. C.

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X |, "^^ / VJ^' — s- V f 1 J^ -^w J'^^^ i"- \ X o \ , w s Sriv X A ' 5 A 7 ^2 ^ Irf f mm^ P fl u ^ oeo/yr/eT. ALA O /C.vV> SUMTC1l_\CR*S P O Y/s <(BCRt! O < 8 H n z z ^ K / ./^' ./ , / / .) A N o X L - z o 7i H I -kSn m m H z > \ N V u. r o > O r z > "; O o^I 7-^ ^^ lA* . «ii / ,r^' > ■< r > z o ^^ o o § 1 s s- M ■^ 00 o © p ^ ^ » 3 3 3 n n a o o o r* It- O O O 3 3 3 E-HOKUIS ^£rER5 CO., WASHtSOTON, D. c THE NOKKIS PSTBRS CO., WASMINGTON, D. C THE NOflKIS fETEKS CO., WA3lflN0T0N, D. C THE NOHRIS CO., WASHINGTON, 1 THE HOKRIS FSTgHS C THE NQRItIS PETERS CO., M ti,--> APPENDIJi. The Florida State Department of Health had instituted a campaign against hookworm disease before the Rockefeller Sanitary Commission was organized. In response to Dr. J. Y. Porter's very cordial invitation, the administrative sec- retary of the Commission and many of the State directors of sanitation visited Florida early in the year to study the methods and results of that work. Not only are we person- ally indebted to Dr. Porter and his staff for many courte- sies, but to them the service is indebted for cordial co- operation and helpful suggestion at every point. We have asked the privilege of appending this summary of the work in Florida for its intrinsic merit and as an acknowledgment of our indebtedness to the work and workers in that State. • Fi,ORiDA State Board oif Health. A Summary of Hookworm Work Accomplished in Florida from October 12, 1909, to December 31, 1910. MILEAGE. The State health officer and three assistant State health officers during this period, in travel chargeable to hook- worm disease, covered — By railway 6,220 miles By teams 1,070 miles By boats 330 miles A total of 7,620 miles (31) 3^ tHt ROCK%^ti^t,tR Sanitary cdMMiSsioN i^oR EXPENSES INCURRED. Salaries of two assistant State health officers while actively engaged in the hookworm cam- paign $1,508.30 Travel expenses during the same period (an average per man per month of $97) 1,057. 15 Total expended by the two field men . . $2,565 . 45 Cost of hookworm literature during 1909 and 1910, which includes circular letters, case rec- ord blanks, and 20,000 leaflets for popular distribution 65 .00 Cost of that portion of Florida Health Notes, the monthly bulletin, devoted to hookworm disease, being 72 pages, or 41^ monthly issues of 16 pages, with a circulation per month of 17,000, and equivalent to 1,224,000 pages 592.00 Laboratory salaries and maintenance, 1909, chargeable 525 . 00 Laboratory salaries and maintenance, 1910, ' chargeable 2,650.00 Six hundred and two indigent cases treated, treatment paid for by State board of health, at $3 each 1,806.00 Travel expenses of State health officer and as- sistant State Health Officer Byrd, in inspec- tions, delivering lectures, etc 534.00 Total expense $8,737.45 YhB Eradication of hookworm disease. 33 Synopsis of the Work Accomplished by Two Assistant State Health Officers. TIME ENGAGED. October 12, 1909, to March 24, 1910 163 days January 3, 1910, to May 11, 1910 128 days August 28, 1910, to September 30, 1910 33 days Number of days in the field 324 MILEAGE TRAVEI-ED. By_ rail 3,360 miles By teams 1,070 miles By boats 330 miles Total 4,400 miles Three thousand two hundred and twenty-seven suspicious cases of hookworm disease found. MICROSCOPICAI, EXAMINATIONS MADE. Positive 399 Negative 179 Total 578 Inspected 79 white schools ; 4 negro schools. Visited 94 towns in 10 counties. Lectures before public audiences 13 Lectures before school children 79 Lectures delivered by Dr. Byrd 14 Total 108 34 THE ROCKEPEIIvLER SANITARY COMMISSION FOR Other work accomplished during the same period: Two outbreaks of scarlet fever directed. Four conferences regarding disposal of city sewage. Two smallpox cases isolated and cared for. Two epidemics of typhoid fever investigated. Prevalence of catarrhal and follicular conjunctivitis re- ported in five schools. Record of Cases. Under the plan of the State board of health to pay physicians three dollars for treatment of indigent cases of hookworm disease, 602 cases have, during the year 1910, been paid for. Conforming to the minimum requirement of the board in the matter of treatment, 67.87 per cent of these 602 cases were cured. Twenty-three cases — 3.8 per cent of the series — were also freed of the worms, the treatment pro- gressing beyond the minimum requirement up to four, five, seven, and nine courses of treatment. It is found that this plan has been taken advantage of by 45 physicians in 23 counties of the State. The patients so treated were distributed over 78 towns in the 23 counties. Hookworm Bxaminations Made in the Bacteriological Laboratories. 1904 to 1908, one laboratory 507 specimens 1909, with one laboratory, 248 positive, 397 negative, and 23 unfit f of examination 668 specimens In March, 1910, a bacteriological laboratory was estab- lished by the State board of health at Tampa, and in July, 1910, an additional laboratory was established in Pensacola, Fla. The central laboratory is located at Jacksonville. TH}^ ERADICATION OF HOOKWORM DISEASE. 35 During 1910 the three laboratories examined 16,095 dis- ease specimens of all kinds. Of this number 45 per cent, or 7,402, have been examinations for the hookworm. Fifty- two per cent of the specimens of all kinds received at the Jacksonville laboratory were submitted for examination for hookworms ; 28 per cent of the specimens received at the Tampa laboratory were for hookworm examination, and 33 per cent of those received at the Pensacola laboratory were for this examination. Bxaminations for Animal Parasites at the Three Laboratories, 1910. HOOKWORMS. Positive. Negative. Unfit. Total. January.. . . February . . March April May June July August . . . . September . October November . December. . Total. 210 205 446 362 424 309 41S 430 454 370 304 224 151 165 293 262 348 295 3" 341 393 221 219 177 4,153 3.176 12 2 O 8 19 II 8 8 2 3 o o 73 Number of examinations for other parasites Add to this the examinations by two assistant ( Positive, 399 State officers in the field \ Negative, 179 373 372 739 632 791 615 734 779 849 594 523 401 7,402 308 578 Total number of examinations 8,288 Four thousand five hundred and fifty-two, or 61.49 P^r cent, of the above examinations were positive for hook- worms. 36 THE ROCKEFELLER SANITARY COMMISSION FOR The examinations for parasites other than the hookworm were divided as follows: Amoeba coli 2 Ascaris lumbricoides 73 Lamblia intestinalis i Oxyuris vermicularis 19 Strongyloides intestinalis 8 Tapeworms 95 Trichocephalus dispar 106 Unidentified eggs 4 Total 308 Of these 308 specimens, 67 were examined in the field by two assistant State health officers, and 241 were examined by two of the laboratories. During 19 10 the laboratory at Jacksonville has sent out in the State 10,004 containers for submitting specimens for examination for hookworm disease, 12 per cent of which have not been returned. During 1910 specimens of all kinds were received from 562 physicians in 197 towns, distributed among all of the 47 counties. During 191 o specimens have been received from 34 towns in which no physician lives. These 34 towns are distributed over 17 counties. One thousand physicians are licensed to practice in Flor- ida. Specimens of all kinds have been received from a little more than 50 per cent of them. Results of the Campaign. An attempt was made to determine the number of cases of hookworm disease treated in five counties which had, six months before, been thoroughly gone over in the cam- THE ERADICATION Olf HOOKWORM DISEASE. 37 paign by the assistant State health officers. This territory was canvassed again, and every physician interviewed and information obtained as to the number of cases he had treated. It was found that 66 physicians in 24 towns had treated 3,142 cases. Extending the investigation, it was found that 562 physi- cians, in 197 towns distributed over the 47 counties, had submitted specimens of all kinds to the laboratories for ex- amination during 1910. Two hundred and one of these physicians in 39 towns did not, however, submit hookworm specimens; but 58 of these 201 physicians, it is known, and who live in 33 towns, are treating hookworm disease. Among these 58 physicians are many of the pioneers in this work, who use their own microscope for diagnostic pur- poses. Assuming that the physicians interviewed represent an average, then the 419 physicians, it will be ,seen, have treated 20,000 cases, 60 per cent of which were cured. This does not account for the other 500 physicians in Florida who have not submitted specimens to the laboratories, but many of whom, if not all, have been treating the disease. Quite recently a map of Florida was taken, and with the Medical Directory of the American Medical Association and office records of the board as guides, a tack was placed at every town where there is one or more physicians. At such towns as it was known that hookworm disease was being treated, a black-headed tack was placed. At other places a red-headed tack was placed. It is found that the black- headed tacks are far in the ascendency, and that as our in- formation becomes more and more complete the red-headed tacks are often disappearing from the map. It is believed at the present time that there is hardly a physician in the State not treating hookworm disease. This belief is based upon the fact that for the last several months not one such has been encountered, notwithstanding a corps of four or five physicians have been covering the State in all directions. 38 THE ROCKEFEI/IvER SANITARY COMMISSION EOR It may be said at this juncture that the hookworm work in Florida would continue to go on, even though the board took no further part in it ; that the hookworm problem will now solve itself, so far as it can be solved; that people in all walks of life, when indisposed from any cause they do not understand, suspect hookworms, and have examinations made accordingly; that hookworm information is now household information, and these things, after all, are the most that can be hoped for in this generation. It is the intention of the board to continue payment for the treatrnent of indigent cases and to continue publishing literature on hookworm disease, to continue the educational crusade, but it believes that the great mass of the important work in this direction is behind rather than ahead. Publication No. 4 STATE SYSTEMS OF PUBLIC HEALTH IN TWELVE SOUTHERN STATES rcx:kefeller sanitary commission washington, d. c. 1911 S WASHINGTON^ D. C. PRESS OF JUDD & DETWEILER, INC., I9II. INTRODUCTORY NOTE Soon after taking up the work of the Rockefeller Sanitary Commission my attention was called to the fact that the work got under way more readily and accomplished results more easily in some States than in others. I became convinced that one important factor entering into this difference in results was difference of effectiveness in the State organization of the public health service. A man can accomplish most when the tools with which he works are adapted to the work which he is doing. This led me to a study of the organization of the public health service in each of these twelve States. The analy- sis here given was made primarily for my own satisfaction and guidance. A copy of it was sent in manuscript form to each of the State boards of Health. The demand for additional copies has made it seem advisable to print a small edition of it for free distribution. WicKLii-']?]j Rose. ALABAMA State System of Public Health I. State department of health. 1. State board of health: a. Organized 1873. b. Membership : The entire State medical association. c. Legal qualifications : Must be a licensed physician ; member of State and county medical association. d. Term of office : For life or during good standing. e. Powers and duties : * (i) Enforces public health laws. (2) Investigates causes, modes of propagation, means of prevention of endemic, epi- demic, infectious and contagious diseases. (3) Investigates influence of localities and em- ployments on health of people. (4) Inspects public buildings, as schools, court- houses, public dairies, slaughter-pens, etc. (5) Inspects water supplies. (6) Regulates sanitation of depots and passen- ger trains. (7) Has supervision and control over county boards of health. (8) Advises State in all sanitary and medical matters. /. Compensation : Expenses of attendance on meet- ings. 2. State committee of public health: The Medical x\sso- ciation of Alabama selects ten censors for a term of five years ; they retire in groups of two. When organized they constitute a board which acts in three capacities : * Medical Laws of Alabama, 1909, page 16. (j) THE ROCKEFELLER SANITARY COMMISSION a. As a Board of Censors. h. As a State Board of Examiners. c. As a State Committee of Public Health. This State Committee of Public Health is the executive agency corresponding to the State Board of Health in most States. It reports to the State Board of Health. 3. Executive officers : a. Chief executive officer : (i) Title: State Health Officer. (2) Appointed: Elected by the State Commit- tee of Public Health, confirmed by the Medical Association. (3) Term of office: Five years. (4) Legal qualifications: Must be member of College of Councilors in State Medical Association. In practice member of committee. (5) Powers and duties: Is executive officer of State Board of Health; supervises local health agencies ; executes laws and regu- lations of board. (6) Compensation: $5,000 per annum. h. Assistants : ( 1 ) Bacteriologist and pathologist : Appointed by board ; salary, $2,500. (2) Registrar of vital and mortuary statistics: Appointed by board. (3) Chief clerk and one stenographer. 4. State laboratory: a. Located at Montgomery. b. Established 1908. c. Value of equipment : $3,000. d. Lines of work regularly pursued: Pathological and bacteriological examination of mate- rial from any source in State, including milk and water supplies. Pasteur treat- ment free. STATE SYSTEMS OF PUBLIC HEALTH "J e. Staff : State bacteriologist and three assistants. /. Expenditures : Records not available. 5. Available funds for State health department : a. Source ; Appropriation by legislature. h. Total amount for year 1909-1910: $16,000. Note. — An additional $20,000 is available for quarantine purposes in case of epidemics. c. How used : For salaries, traveling expenses, printing and office expenses, traveling expenses of State committee of public health, laboratory supplies. II. Local health organizations. I. County organizations : a. Name : County board of health. h. How constituted : County medical society organ- ized under constitution of the State medi- cal association is the county board of health. c. Duties, authorities and powers : (i) Supervises administration of State health laws in county. (2) Investigates cases of endemic, epidemic, in- fectious and contagious diseases and en- forces measures of relief. (3) Abates public nuisances. (4) Supervises sanitation of public buildings. (5) Elects county health officer. (6) Elects health officer for every incorporated city or town in county. (7) Elects physician to attend inmates of county poorhouse and jail and fixes his term of office. (8) Requires annual reports of county and mu- nicipal health officers showing all public health work done and giving vital and mortuary statistics. THE ROCKEIFELLER SANITARY COMMISSION (9) Requires county health officer to send State board of heahh monthly report of births and deaths in county. (10) Performs all duties required by law. d. Relation to State board of health: Under general supervision and control of State board of health. e. Executive officers : (i) Title: County Health Officer. (2) Elected: By county board of health. (3) Term of office: Fixed by county board of health. (4) Duties: (a) Keeps register of births; of deaths; of persons attacked by communi- cable diseases. (b) Supervises sanitary- conditions of county. (c) Investigates and reports outbreaks of communicable diseases. (d) Supplies virus and vaccinates indi- gent persons at expense of county. (e) Inspects all county institutions once each month. (/) Makes monthly report of births and deaths to State board of health. (g) Reports annually to judge of pro- bate and county commissioners all public health and sanitary work done during year, with rec- ommendations. (h) Reports promptly to State board of health cases of communicable dis- eases. (i) Reports to county board of health when required. STATE SYSTEMS OF PUBLIC HEALTH 9 ( 5 ) Compensation : Fixed by county commis- sioners; minimum salary, $io per thou- sand of population for counties of 10,000 inhabitants or less ; decrease of above rate not to exceed 10 cents per thousand of population up to a population of 100,- 000 ; beyond this no further decrease. Salaries range from $200 to $1,800 a year. Average for all counties, $500. 2. Municipal organization: a. Board of health: The county board of health is the board of health for all incorporated towns and cities in county. b. City health officer : ( 1 ) Elected by county board of health. (2) Term of office: Fixed by county board of health. (3) Duties: Within his jurisdiction similar to duties of county health officer for county outside municipalities. Reports to county health officer, to mayor and council, to county board of health. (4) Compensation: Fixed by municipal authori- ties ; paid from municipal funds. III. Medical societies in the State. 1. The State medical society: a. Name : Medical Association of Alabama. b. Organized 1847; reorganized 1873. c. Number of members: 1,685. d. Meetings : Annually. e. Attendance at meetings : 350 to 500. /. Official connection with State health department: State health department is responsible to State medical association and renders a report thereto summarizing its work. 2. County medical societies : a. Number : 67 ; every county in the State organized. lO THE ROCKEFELLER SANITARY COMMISSION b. Meetings : \^arying from 2 to 54 meetings a year ; average for all counties, 6 plus. c. Number of members : Varying from 4 to 236 ; average for all counties, 24 plus. d. Efficiency : Of the 67 counties organized, 33 are reported as good, very good, or excel- lent ; 6 as unsatisfactory ; the remaining 28 as fair to fairly good. 3. City medical societies : Organized and efficient in larger towns and cities. Note. — No district medical societies in Alabama. STATE SYSTEMS OF PUBLIC HEALTH II ARKANSAS State System of Public Health I. The State department of health. 1. State board of health: a. Organized 1881. b. Number of members : 6. c. Appointed by the Governor. d. Legal qualifications : All must be physicians ; ma- jority must be graduates having at least 7 years' experience. e. Term of office : Two years. /. Duties : Legislative and advisory on public health matters. g. Compensation : None. 2. Executive oiiScers : a. Chief executive officer : ( 1 ) Title : Secretary State Board of Health. (2) Appointed: Elected by the board. (3") Term of office: Two years. (4) Legal qualifications : Shall have skill in public health and sanitary service. (5) Duties: Is executive officer of the board; has powers and privileges of a member of board. (6) Compensation: None. b. Assistants : Board may engage suitable persons to render public health services when neces- sity requires. No one regularly em- ployed. 3. State laboratory: None. 4. Available funds: No available funds for State board of health. State has never made appro- priation for public health purposes. The board is not active ; has never maintained an office. 12 THE ROCKEFELLER SANITARY COMMISSION II. Local health organizations. I . County organizations : 0. County board of health. b. How constituted : Three members ; appointed by county judge. c. Term of office : Two years. d. Duties : General control of public health. Powers rarely exercised. e. Compensation : None. County judge may in his discretion allow compensation for special services. /. Number in State : Most counties have an organi- zation in form ; they rarely function. 2. Municipal organizations : a. City board of health : Provided for by city char- ters. b. How constituted : Each city has its own method. Usually chiefs of departments constitute board of health ; city physician chief health officer. In some cases board is appointed by city council ; in smaller cities or towns by mayor. Term usually about two years. c. Duties : City boards of health have full powers to control health affairs of the city. d. Compensation: Compensation allowed health offi- cer varies in different cities ; in Little Rock he is allowed $900 a year. III. Medical societies in State. I. The State medical society: a. Name : Arkansas Medical Society. b. Organized 1874. c. Number of members: 1,000. d. Meetings : Annually in May. e. Attendance at meetings : Average about 350. STATE SYSTEMS OF PUBLIC HEAI^TH I3 /. Official connection with State board of health: None. State society has committee on medical legislation and takes an active interest in laws looking toward the bet- terment of public health. 2. County medical societies ; a. Number: 64 (75 counties in State). h. Meetings : Usually monthly. In some counties annually. c. Efficiency : Majority reported as indifferent : few counties doing active scientific work. 3. District medical societies : Four in State ; reported as active and as having excellent semi- annual programs. 4. City medical societies : None. IV. Other agencies. 1. Associations for the prevention and control of tuber- culosis. 2. A few associations for the prevention of blindness. 14 THE ROCKEFELLER SANITARY COMMISSION FLORIDA State System of Public Health I. State department of health. I. State board of health: a. Organized 1889. b. Number of members : 3. c. Appointed by the Governor, confirmed by the Senate. d. Legal qualifications: Must be "discreet citizens"; custom has made one a physician. e. Term of office : Four years. /. Powers and duties : (i) To have general supervision of the public health of the State. (2) To make, adopt, promulgate and enforce rules and regulations to provide for sani- tation of all vehicles of transportation ; of all hotels, schools, factories and build- ings open to the public ; to provide for proper care of all animals having com- municable or infectious diseases ; to pro- vide for proper care of all persons sus- pected of having communicable diseases ; to regulate disposition of garbage, sewer- age and refuse ; to provide for thorough investigation and study of all diseases in State and dissemination of knowledge concerning the same; to supervise and regulate city and county sanitation; and in general provide such measures as may be deemed necessary to preserve the public health. (3) To adopt and enforce quarantine regula- tions. State board has control of mari- STATE SYSTEMS OF PUBLIC HEALTH 15 time and domestic quarantine system of State. No place can operate quarantine without authority from State board. It is made the duty of the Governor to furnish State board means to enforce quarantine regulations. (4) To employ a sanitary engineer when neces- sary and provide for his compensation. (5) To acquire, maintain and administer a sani- tarium for the treatment of tuberculosis. (6) To define and abate all public nuisances. (7) To quarantine against infected animals. (8) To maintain and administer a bureau of vital and mortuary statistics. (9) To require physicians to report immediately cases of yellow fever, smallpox, cholera, diphtheria, leprosy, scarlet fever. (10) To elect a State health officer, who serves as the executive officer of the board. (11) To report annually to the Governor. Note. — All rules and regulations of the State board of health have the force of law. g. Compensation : $6 per day of actual service and mileage. 2. Executive officers : a. Chief executive officer: ( 1 ) Title : Secretary and State Health Officer. (2) Appointed: Elected by the State board of health. (3) Term of office: Four years. (4) Legal qualifications : Must be a graduate physician of a reputable medical college ; an expert in diagnosis of yellow fever, smallpox, cholera and other infectious diseases ; a person of recognized ability in hygiene and sanitary science. l6 THE ROCKEFELLER SANITARY COMMISSION (5) Duties and powers: (o) Acts as secretary of State board of health. (b) Has executive control of quarantine system of the State. (c) As executive officer of the State board administers and enforces all laws, rules and regulations for the preservation of public health. (d) Employs, with approval of presi- dent of the board, persons to serve as county agents, as special agents and to perform such other duties as are necessary for the preservation of public health. (e) Compensation: $3,000 per year. b. Assistants : (i) Secretary to State Health Officer at salary of $2,500. (2) Veterinarian at salary of $1,600. (3) Two assistants who serve as field agents of the State Health Officer at salary of $1,800 each. (4) Two clerks and office boy. (5) Laboratory staff for three laboratories. (6) Nineteen county agents. (7) Five sanitary patrolmen ; one each for Jack- sonville, Pensacola, Tampa, Key West, Miami. 3. State laboratories: a. Number : 3. b. Located: Jacksonville, Tampa, Pensacola. c. Established: 1902. 1910. 1910. d. For what purposes used: General bacteriological laboratories for examining specimens of suspected diphtheria, tuberculosis, mala- ria, typhoid, ophthalmia, cancer, etc. Ad- tninisters Pasteur treatment. state; systems of public heaiyone. 2. County medical societies : a. Number: 67. There are 96 counties in State. b. Meetings: Some weekly; some bi-monthly: some monthly ; some not at all. c. Number of members: In the 67 societies. T.400. Average membership 21. d. Efficiency: Varying from complete inactivit\- to a very high degree of efficiency. 3. District medical societies : a. Number: Four— the Upper Cumberland, the -East Tennessee, the Middle Tennessee and the West Tennessee societies. STATE SYSTEMS OE PUP.I,IC HEALTH 51 b. Relation to State and county societies : No affilia- tion. c. Efficiency : All very efficient bodies. 4. City medical societies : In the counties in which large cities are located the city societies and county societies are identical and have weekly meetings. IV. Other agencies. r. Anti-tuberculosis leagues in various cities. 2. Civic improvement leagues. 3. School improvement associations which give attention to sanitary conditions at public schools. 52 THE ROCKEFELLER SANITARY COMMISSION TEXAS State System of Public Health I. State department of health. I. State board of health : a. Organized ; reorganized 1909. b. Number of members : Seven. c. Appointed by the Governor. d. Legal qualifications : Legally qualified practicing physician ; graduate of reputable medical college ; ten years' experience in practice of medicine. e. Term of office : Two years. /. Duties and powers : ( 1 ) To have general supervision and control of all matters pertaining to the health of the citizens of the State. (2) To make study of the causes and preven- tion of infectious and contagious dis- eases within the State. (3) To have direction and control of quaran- tine. (4) Is given power to prepare a Sanitary Code for Texas, which, when made, adopted, approved by the Governor, published and promulgated, shall have the force of law in all respects as far as relates to the following subjects: (o) The management of quarantine and disinfection with respect to all contagious and infectious dis- eases. {b) The government of quarantine and disinfection of all pestilential diseases, such as cholera, leprosy, bubonic plague, typhus and yel- low fever. STATE SYSTEMS OF PUBUC HEAIvTH 53 (c) Inspection, sanitation and disinfec- tion of public carriers, places of public resort; the regulation of water, ventilation and heat in all such places. (d) Governing the reporting by physi- cians and health officers of the presence in any locality of all contagious and infectious dis- eases. (e) The collecting of vital and mortu- ary statistics. (/) Governing transportation of dead bodies. (5) To prepare an advisory supplement to such Sanitary Code containing rules and regu- lations on the following subjects: (a) Fixing standard for disinfectants. (b) Sanitary disposition of sewage. (c) Interment and disinterment of dead bodies. (d) Inspection of animals to be used for food products. (e) The sanitary condition of slaugh- ter-houses, meat-markets, dairies. (/) Sanitation of pubHc buildings. (g) Sanitation of all food-markets and methods of marketing foods. Note. — This advisory supplement is given the authority of law in cities and towns when adopted by majority vote of city council ; and adoption by majority vote of commissioners' court gives it force of law in county outside of cities and towns. (6) Is given power to revise and amend Sani- tary Code. Code and revisions have full force of law, with penalties attached. 54 THK ROCKEl'lil^LER SANITARY COMillSSIOX (7) The board and its members given full power to enforce public health measures. g. Compensation : Ten dollars per day of actual service and 3 cents mileage. 2. Executive officers : a. Chief executive officer : ( 1 ) Title : State Health Officer. (2) Appointed by the Governor, confirmed by the Senate. (3) Term of office: Two years. (4) Legal qualifications : Legally qualified gradu- ate of reputable medical college; skilled in public sanitation; ten years' experi- ence in practice. (5) Duties: President and executive officer of the board. (6) Compensation: $2,500 a year and traveling expenses. b. Assistants : ( 1 ) Assistant health officer : Appointed by President of board with approval of the Governor; salary $2,400 a year. (Office vacant at present for lack of funds.) (2) Registrar of vital statistics: Secretary of board; appointed by President of board with approval of the Governor; salary $1,800 a year. ( 3) Chemist and bacteriologist : Must be learned in chemistry, pathology and bacteriology : appointed by the President of the board with approval of the Governor ; salary $1,800 a year. (Office vacant at present for lack of funds.) (4) Inspector: To act as sanitary inspector; appointed by President of board ; salary $1,800 a year. (Office vacant at present for lack of funds.) state; sYSTJiMS OF PUBLIC hh;ai,th 55 (5) Stenographer and bookkeeper: Salary $1,200 a year. x\ppointed as above. 3. State laboratory: Provision made for laboratory, but it has not been opened on account of the lack of funds. 4. Available funds : a. Source: Legislative appropriation. b. Total for last year, $48,195. c. For what used : $12,000 of the appropriation is known as the general maintenance fund and can be used for general sanitary pur- poses. Remainder of fund is consumed in coast and border quarantine. II. Local health organizations. 1 . County organizations : a. How constituted : County health officer appointed'. by county Board of Commissioners. b. Term of office : Two years. c. Duties: Has charge of all public health matters in county outside of incorporated towns and cities. Under general supervision of ,State board of health. d. Compensation : Fixed by Commissioners ; average about $300 to $400 a year. e. Number in State : About 230. 2. Municipal organizations : a. How constituted : City health officer appointed by city council ; if city council neglects or refuses, then by State board. b. Term of office: Two years. c. Duties : Has charge of all public health matters in city under general supervision of State board. d. Compensation : Fixed by city council ; in larger cities about $2,500 a year. c. Number in State : About 280. $6 THg ROCKEFELLER SANITARY COMMISSION III. Medical societies. 1. State medical society: a. Name: State Medical Association of Texas. b. Organized 1868. c. Number of members : About 3,300. d. Meetings: Annually in May. e. Attendance at meetings : 500 to 800. /. Official connection with State department of health : None. 2. County medical societies: a. Number: About 200. b. Meetings : Bi-monthly to semi-annually. c. Members : Variable. d. Efficiency : From very good to mere existence. 3. District medical societies : 1 5 districts in State ; prac- tically all have societies; six of these in good condition. 4. City medical societies : None. IV. Other agencies. 1. Civic leagues. 2. Women's clubs. STATU SYSTEMS OF PUBLIC HEALTH 57 VIRGINIA State System of Public Health I. State department of health. I. State board of health: a. Organized ; reorganized 1908. b. Members : Twelve. c. Appointed by the Governor. d. Legal qualifications : Must be a member .of State medical association ; one physician from each of the ten congressional districts of the State and two physicians from the city of Richmond. e. Term of office: Four years, retiring in groups of three. /. Powers and duties : (i) To establish and maintain in city of Rich- mond suitable laboratories for examina- tion of clinical material. (2) To make research and studies of epidemics of infectious diseases and of methods of preventing and curing diseases. (3) To establish and maintain at suitable place State sanitarium for treatment of tuber- culosis. (4) Is given power to make and promulgate rules and regulations for the protection of the public health of the State. These rules and regulations have the force of law with penalty for violation or refusal to obey. Note. — The State board is thus clothed with all power needed. g. Compensation : $8 per day of actual service and ID cents mileage. 58 THE ROCKEFELLER SANITARY COMMISSION 2. Executive officers : a. Chief executive officer : ( 1 ) Title : State Health Commissioner. (2) Appointed by the Governor. (3) Term of office: Four years. (4) Legal qualifications: Shall be a physician skilled in bacteriology and sanitary science. (5) Duties: Executive officer of the State; has all the powers of the board when it is not in session. (6) Compensation: $3,500 a year. b. Assistants : (i) Assistant ,CDiumissioneT: Appointed by Commissioner; term four years; has charge of contagious and infectious dis- ease work ; looks after the bulletin ; acts in absence of Commissioner. ( 2) Bacteriologist : Appointed by Commissioner ; term of four years ; has charge of labora- tory; salary $2,500. (3) Clerk: Appointed by Commissioner; salary $1,200; detailed for duty at sanitarium. (4) Two clerks: One a stenographer, at $6oo ; janitor at $320, who aids in laborator)'. 3 State laboratory : a. Located at Richmond. h. Established 1908. c. Value of equipment: $3,500. d. For what used : Free diagnosis of specimens sub- mitted by physicians from cases of ty- phoid, tuberculosis, diphtheria, malaria, hookworm, special problems of water, foods and sewage. e. Staff: Bacteriologist and janitor. Note. — The Pasteur Institute of Virginia is lo- cated in same building. This is a private STATE SYSTEMS OF PUBJ^IC HlUl.TJl 59 institution ; makes diagnosis for rabies free. /. Expenditures : No regular amount ; funds are sup- plied as needed from general funds of department. 4. Available funds : a. Source : Legislative appropriations ; made bien- nially. b. Total amount for 1909: $40,000. c. For what used: Salaries, traveling, laboratory, educational work, purchase and mainte- nance of sanitarium for tuberculosis. general health measures. IT. Local health organizations. I. County organizations: a. Name : County Board of Health. b. How constituted : Five members ; chairman of the Board of Supervisors is chairman of the board of health ; clerk of the Count)' Court is ex officio a member; three phy- sicians are appointed by the judge of the Circuit Court; one of these three is se- lected secretary and executive officer. No term specified. c. Executive officer: Elected by board from its own membership ; term of 2 years ; executive officer of board ; compensation fixed by board with consent of Board of Super- visors. Note. — Usually no regular compensation, but al- lowances for special services. d. Powers and duties : Has general charge of sani- tary officers of county ; has control of prevention and eradication of contagious and infectious diseases, removal and quarantine of suspects ; provides for com- 6o THE ROCKeFELI^ER SANITARY COMMISSION pulsory vaccination ; power to adopt and enforce such rules and regulations as are necessary to effect these ends. Note. — I. Powers limited by absence of penalties. 2. When county authorities fail to create health organization for county, State board of health may exercise the au- thority and appoint health officer. 2. Municipal organization : a. How constituted: Varies according to charters of cities ; usually city or town board of health with one member acting as health officer. b. Appointed : Board usually appointed by city coun- cil. c. Term of office : Varying from two to four years. d. Duties: Usually have full power to control sani- tary affairs of municipality. e. Compensation : Varies ; usually very small ; paid to physician who devotes his time to pri- vate practice. Richmond and Norfolk have active, efficient departments of health. III. Medical societies. 1. State Medical Society: a. Name : Medical Society of Virginia. b. Organized . c. Number of members: About 1,300 (2,000 physi- cians in State). d. Meetings : Annually. e. Attendance at meetings : Usually from 300 to 500. /. Official connection with State department of health : None. Unofficial relations inti- mate and cordial. 2. County medical societies : a. Number: Sixteen (one hundred counties in State). b. Meetings : Usually monthly. STATE SYSTEMS OF PUBI^IC HEAI^TH 6l c. Numbers of members : Vary widely. d. Efficiency : Some reported doing excellent work, some as almost defunct. 3. District societies : District medical societies embrace practically the whole State; reported that most of them are in healthy condi- tion. 4. City medical societies : Practically every city in the State has a thriving medical society ; those in the larger cities are very influ- ential. IV. Other agencies. 1. Health leagues in many cities. 2. Civic improvement leagues in many cities ; neighbor- hood improvement leagues in some coun- ties. (>2 THE ROCKEFELLER SANITARY COMMISSION <, '■s^ 05 e ! n a 2 tf] > 1 -'* 5> 1 s •3 a ^ t u )■• Q d 1!, 3 CO 1 3 d > a > en si g> i gl C5 s en 13 V a' > C5 S. £'? Authority of sanitary code. ■6 OJ 1 3 •0" 1 3 1; 1 ■d 1 3 Si 1- ■d V 1 ■3 1 a 3 •d a 3 '6 V 1 ^ Hi" X Does State board elect health officer ? ca v > >< d 4> >< is P4 w v >* 1 c Z f y 10 V i * .5 w' W el <0 cd 5 " ii s PS ^1- Is CO V >, us "1 ifS t s V a « ''5 «* £.0 1° 3 is" . as:5 5 "^ -J) .2 a •a°ti Sag sal 3 'u a •a 3 CO ;d J? P. 1 d ►J ■350 ■Z " in >> .. J=j: • ftoto V —. .^Sa BS.g Is BS (fl " lis a1 Bl w 00 (0 a S *3 ■s >> 13 « 1 :sg fl ■-■0 a. 2 1 1 '^ a: i 5 1 '~ 1 C 1- am a >. a aoj OS a 3. 0° sen ^! u on g 10 a^ OOK 5a5 00 S s > to c Ih > >t i c ! |J ^ a *g VD rn N 00 r» « o\ *o ■* t^ N ' IP i 1^ 0'" 00 00 00 s 1 OS t 00 oc 00 1' 1 1 ] 01 i (A C 1 ■a t 1 Hi 5 1 01 1 ol' a 1 a 1 a a g 4^ ■a 1 > STATE SYSTEMS OF PUBI^IC HEA1,TH 63 V c |1 i ' 1 N I i 8 ^ 1 1 § 8 ■3 IE II u U Si 1- ii •0 u V u Si w Ir oS (4-. 1 o-d > g Ii w .S-oS ^ apq a a J, 1" O+j Eg So ■ & .£ 1- MO i- ■oS III ft, 0^ Hi < s.' 1 1 III COS en 1 '3 a ■0 V . 3. a Xi Ii .53 w J n a 1 ■s Id 1 il h4 a 1 ft V tn ■& P4 t ft ■0 V 1 •d . u a 5-2 ^u CO a •0 a •as- 1" •0 a a 1 2g a- .aft 3.S as — la- a& ■-1 .-;: a 5i 'Si 1 1 <*- a ,11 a 10 2 2 >> S2 cd u Si, s Hi 3 ♦!o ■ CO V ■/i r ! i 1 11 § n 1 § n n n a 5- ■E g n ■E 3 n lis "is OgW !-" = •E CO W ss s li' S u i 1 i! 01 ■E CO s V IS so CO Oi CIt Is; t,0 a- (0 1 ■a" £•1 Bo en £• 01 U ■Ji ■E a, ■E g V cs OJ i a '2 ^^ a V tn u § cd w a 5 h •io CO ii en E i 5 ■c E •s s > n V C4 a n ;« c •5 1 S a c a u S 1? rt 1 a u s 1 a (LI a H en '3 1 > 64 THE rockefh;i,ler sanitary commission ^ 0^ •s a ! c o 1 •s CO E a u £>. 'Si "to '5) •l> .2^B si* > 4-) u] cd «.23ii .»sas 1 .2 1 Cd > a "in If d o 1 i P- cd > ■& a o ■s CO •c 1 1 In a o 1 p. s p. p. 1 ■a 5 5 -■t o " tn c^ n 2b o " >5 8 O s 2 s o ^ "»t m" 8 O s 1 la 00 1 ►J M to ""d- 00 "* TO u d S E < CI M cd 1 s Q > Cd i 3 ■s p 'I 1 s cd' a 1 1 cd a 1 5 o (J C-i 1 Bo-a M V S C1.V o 4J O K g"S.S ?£^ ^ O Pi Cd UCA * is "cd"* ** o^ o (d (»*»-■ o o Q W-M4A STATE SYSTEMS OF PUBLIC HEALTH 65 SUMMARY OF FACTS AND OBSERVATIONS 1. In Florida, Kentucky, and Louisiana, members of the State board of health are appointed by the Governor and the appointment confirmed by the Senate; in North Carolina 5 members are appointed by the Governor and 4 by the State Medical Society; in South Carolina 8 of the 10 members are appointed by the Governor on the recommendation of the State Medical Society. This method of appointing members of the State board of health has a twofold merit : a. By giving the Governor a voice in the appointment of the board it recognizes the executive head of the State as responsi- ble to the people for the efficiency of every department of the public service; it tends to make the State system of public health responsible to the public which it serves. In the ap- pointment of its State board of education New York State seems to accomplish the same end successfully by having the board appointed by the Legislature. h. Requiring that appointments be confirmed by the Senate or that they be made on the recommendation of the State Medical Society tends to provide against arbitrary use or abuse of the appointing power. In the discharge of its duties it frequently becomes necessary for a State board of health to be courageous in the exercise of its power ; it is of the utmost importance that it be protected from undue political interfer- ence. How this interest may be further safeguarded is illus- trated under the next head. 2. In North Carolina the State board of health has 9 mem- bers holding office for 6 years and retiring in groups of 3. Long term of service with members retiring in small groups guarantees that degree of continuity which is necessary to effective service ; it serves also as an effective safeguard against undue political interference. This principle is embodied with varying degrees of effectiveness in the State boards of Virginia, North Carolina, Louisiana, Georgia, and Alabama. 66 THE ROCKEFELLER SANITARY COMMISSION 3. In Alabama, Arkansas, Florida, Georgia, Kentucky, Mis- sissippi, North Carolina, and Tennessee the State board elects its own executive officer. Giving the board this authority has the virtue of centering responsibility and power in the same administrative body. If the board be held responsible for the service, it should have the power to select its executive agent; to fix his salary; to keep him at his post as long as he is effi- cient. 4. In Florida, Louisiana, Texas, and Virginia the State board of health has been given the power to make and pro- mulgate a sanitary code having the full force of law ; to revise the code at discretion ; to- enforce the code that it promulgates. This tends to make the power of the board commensurate with its responsibilities. It is difficult to see how any State board can effectively conserve the life and health of the people until it has been thus clothed with full administrative power. 5. The Florida public health fund is on a mill basis and yields this year about $75,000. Thus the fund is stable; it is adequate ; it grows with the needs of the State. Having a definite fund, the board can look far ahead and make definite plans to be carried out through a long series of years. In definitely giving its State board of health full administrative powers and providing it with an adequate fund on a mill basis, the State of Florida sets a high standard. 6. The compensation allowed the State health officer ranges from $500 in Mississippi to $4,500 in Alabama and Louisiana. The salary paid the health officer is not the measure of effi- ciency in the service, but efficient service does require sufficient compensation to justify a competent man in devoting his whole time to the work. 7. One of the most striking features of these State systems of public health is the inefficiency of the county health service. To secure best results in the county service at least two things would seem necessary: a. It would seem to be desirable and possible to organize the county board of health in a way to stimulate and utilize STATB SYSTEMS OF PUBLIC HEALTH 67 local initiative under effective control. The parish health board in Louisiana seems to embody this principle in that it is given the power to make rules and regulations for the protection of health in the parish; the rules and regulations have the force of law; and yet the parish board is under the general super- vision of the State board, must conform to its rules and regu- lations, and must co-operate in executing them. b. It seems evident enough that there can be no effective health service in the county on any basis until there is in the county a capable health officer devoting his whole time to the service. In most States the county health officer is a practicing phy- sician ; he is paid an insignificant sum to look after the health interests of the county, but must depend for the support of himself and his family upon his private practice; it is not his fault that the service is not effective. In some of the States the county health officer is paid by a fee system. The work is not going to be done until the man is paid an adequate salary for his services and is required to devote his whole time to the work.* Washington, D. C, December, 1910. * Since this manuscript was written the Legislature of North Caro- lina has enacted a law authorizing the county to employ a county superintendent of health for his whole time, and to pay him a salary. I am advised that two counties have used the authority thus granted, and now have superintendents of health devoting their whole time to the work. THE ROCKEFELLER SANITARY COMMISSION FOR THE ERADICATION OF HOOKWORM DISEASE SECOND ANNUAL REPORT OFFICES OF THE COMMISSION WASHINGTON, D. C, U. S. A. 1911 THE ROCKEFELLER SANITARY COMMISSION F. T. Gates Chairman WiLtiAM H. Welch Simon Flexner e. a. auderman D. F. Houston P. P. Claxton WicKLiFFE Rose Administrative Secretary 725 Southern Building Washington, D. C. j. y. joyner Walter H. Page H. B. Frissell J. D. Rockefeller, Jr. Starr J. Murphy C. W. Stiles Scientific Secretary 24th and E Sts. N. W. Washington, D. C. L. G. Myers Treasurer CONTENTS. Chapter I. — Outline statement of activities and results by the Administrative Secretary. Chapter II. — Summary of activities and results by States. Chapter III. — General summary. Chapter IV. — Exhibits. Chapter V. — Report of the Scientific Secretary. CHAPTER I. OUTLINE STATEMENT OF ACTIVITIES AND RESULTS BY THE ADMINISTRA- TIVE SECRETARY. The report of the Administrative Secretary for the year 1910 defines the work to be done; it gives an account of the organization of the agencies that are doing the work; it ex- hibits these agencies in action and gives in detail the methods of work in each line of activity pursued. The present report will record in detail only the new developments for the present year and will summarize the activities and results. I. The working agency for 191 1. — The organization as outlined in the report for 1910 has continued; it has grown in size, but we have had no occasion to change its form. Tabular statement No. i exhibits the present working force by States. II. The organization at work. — All lines of activity as exhibited in. the report for 1910, with important additions, have been pursued during the present year. The work in each State is directed as hitherto toward three tasks: determining the distribution and degree of infection; getting the people treated; removing the cause of infection by putting a'stop to soil pollution. I. Determining the distribution and degree of infection. — To this end we are conducting three types of survey : (i) The preliminary survey. — ^The methods of this work are" given in detail in the report for 1910. The results for the 5 OUTI,INE STATfiMgNT BY 2 O pa . ^; u 0) 5 -c ^ ■ J en 2 s 5 ^ « 5 >. L> C3 r; 5 C s OT &; ;W Jffi mi".. §§OQ uj< : c U.5J :'^ § S JL C^ o o p - te: 3 ■" e . .CQ-o CQ(J ■ ° Kd*o P S§ c ot«s ^ ■" §;g:g S! .S •- P P. ■ E o o d < o O o p^ p w O w O THE ADMINISTRATIVE SECRETARY. o O ISb-i c ti% ts-S 111 w fi; § fi; h^ji; ■<■ h^^ h^t^ ^ E-i w ^ ^ ■<■ « B o botes s eu a •S •a o O to S fa m O fa I u hi o "o nl 3 O CO wo V •".Is wtiO 8 outline; statement by two years are here exhibited on maps i to ii. In addition to the States represented on the maps, infection has been demon- strated in Florida, Cahfornia, Nevada, Oklahoma, West Vir- ginia, with very strong clinical evidence of its presence in Maryland. Infection has been demonstrated in 93 of the 100 counties in Virginia; in 99 of the 100 counties in North Caro- lina; in 140 of the 146 counties of Georgia; in every county in South Carolina; in 66 of the 67 counties in Alabama; in 77 of the 79 counties in Mississippi ; in 27 of the 59 parishes in Louisiana; in 57 of the 75 counties in Arkansas; in 95 of the 96 counties in Tennessee; in 22 of the 119 counties in Kentucky. Of the 884 counties in these ten States, infection has been demonstrated in 719; the remaining 165 counties have not been surveyed. This preliminary survey shows (see maps) a heavy infec- tion on the sandy costal plain extending through the eastern part of Virginia, North Carolina, South Carolina, the southern part of Georgia, Alabama, and Mississippi. In many of the counties in this belt the infection is extremely severe. In one such county I visited three public schools in succession in which microscopic examination showed every pupil and the teacher infected. In Louisiana, the heavier infection has been found thus far near the Florida line and in the hilly regions of north Louisiana ; in Arkansas the survey has been confined mainly to the southern part of the State, where a heavy infec- tion has been demonstrated; in Tennessee the heavier infec- tion has been found in the coves, on the slopes, and extending even to the plateau in the western portion of the Cumberland Mountain region. The record of this preliminary survey is subject to correction by the more thorough survey which is now under way. THE ADMINISTRATIVE SECRETARY. 9 (2) Definite survey to determine degree of infection. — In February of the present year, the State directors in conference in Atlanta agreed upon a uniform plan of survey, to determine the degree of infection' for a selected group of the population. The survey is made by counties; it is based on a microscopic examination of foecal specimens from at least 200 children be-» tween the ages of 6 and 18, taken at random — that is, without reference to clinical symptoms — from rural districts distribu- ted over the county. The record shows the number of chil- dren examined, the number found infected, the per cent of infection. This result is taken as an index to the degree of infection among children between the ages of 6 and 18, living in the rural district in the given county. This body of definite information serves a twofold purpose : given to county boards of education, to boards of commission- ers, and to the people, it furnishes a definite basis for action ; by making a similar survey from time to time, it gives a defi-' nite measure of progress in the work of eradicating the dis- ease. This survey is being made in connection with the other work. The results of the work thus far are exhibited as a part of the State reports. The survey has been completed for 87 counties in nine States ; the result shows an infection among the rural children from 6 to 18 years of age in these counties ranging in degree from 2.5 to 90.2 per cent. In the beginning of the work, two years ago, the discovery of heavy infections was discouraging; after two years of ex- perience the record of a heavy infection has the opposite efifect. Where the infection is heavy it is much easier to awaken interest; to get the people to see what the presence of the infection means; to get them to appropriate money for the lO OUTLINE STATEMENT BY dispensaries; to secure cooperation in getting the people ex- amined and treated; to secure definite action in the interest of better sanitation to prevent reinfection. These communi- ties where the infection is heavy are going to be the first to throw it off; they are going to lead in the improvement of •sanitary conditions, which, while stamping out hookworm disease, will at the same time bring under control typhoid, amoebic dysentery, and other enteric diseases. (3) Survey of foreign countries. — The Commission has undertaken to get information on the disease in foreign coun- tries. A letter was prepared asking for information on: i. whether or not the country has been found infected; 2, the geographic distribution of the infection within the country; 3, an approximate estimate of the degree of infection; 4, whether the infection is surface or mine infection ; 5, what is being done by private or public agencies to eradicate or relieve it. Through the good offices of the late Surgeon General Wyman this letter was sent out by the Department of State with a covering letter as an official inquiry to American repre- sentatives in all foreign countries. This was followed by correspondence with physicians and public-health authorities in these countries; these reports were supplemented by refer- ence to the voluminous literature of the subject on file in the library of the Surgeon General's office, U. S. Army. The information thus gained is summarized in Publication No. 6,* "Hookworm Infection in Foreign Countries." Some features of the exhibit in Publication No. 6 call for special attention in this report : * The Rockefeller Sanitary Commission, 725 Southern Building, Washington, D. C. THE ADMINISTRATIVE SECRETARY. II a. Extent of the infection. — Hookworm infection belts the earth in a zone about 66 degrees wide, extending from parallel 36° north to parallel 30° south; practically all countries lying between these two parallels are infected. Of the foreign countries from which the Commission has received reports, 54 are infected. In six of these coun- tries — ^Wales, Germany, Netherlands, Belgium, France, and Spain — the infection is wholly or chiefly confined to mines, and is found in but few definite localities; in at least 46 of these countries the infection is general and widespread. Ex- hibit on page 89 shows that these 46 countries comprise an area of about 14,464,158 square miles and have a population of about 919,858,243. To this we may add 11 of our own States, with an area of 510,149 square miles and a population of 20,785,777. Of the total population of the globe — about 1,600,000,000 people in round numbers — about 940,000,000 live in countries where hookworm disease is prevalent. b. Degree of infection. — In many countries the infection is extremely prevalent. In 1904 it was estimated that 90 out of every 100 of the working population of Porto Rico were in- fected. My own observations in the island convince me that this estimate was not excessive. The reports summarized in Publication No. 6 estimate: That of the whole population of Colombia living between sea-level and 3,000 feet above, 90 per cent are infected, and this includes the great majority of the 5,000,000 of people living in this country; that of the total population of British Guiana, 50 per cent are infected, the percentage of infection among the laborers on the sugar es- tates being much greater; that in Dutch Guiana the infection on many plantations runs as high as 90 per cent; that over a thousand microscopic examinations in French Guiana showed 12 OUTLINE STATEMENT BY an infection of 35 per cent among a local population, 50 per cent among soldiers, and from 50 to 88 per cent among pris- oners ; that in Egypt general estimate places the infection at 50 per cent of the laboring population; that 50 per cent of the coolie laborers on sugar and tea estates in Natal are infected, with the disease spreading among natives and Europeans ; that on many plantations in Ceylon the infection runs as high as 90 per cent ; that of the 300,000,000 of people of India, 60 to 80 out of every 100 harbor the parasite ; that on rubber plan- tations in the Malay States the infection runs from 47 to 74 per cent; that the southern two-thirds of the Chinese Empire is involved with the infection in many places in the Yang-tse Valley running as high as 70 to 76 per cent among the farming population; that of the entire population of American Samoa, about 70 per cent are infected. c. Economic significance of the disease. — The economic loss resulting from the disease is enormous. The physically sound coffee-picker in Porto Rico picks from 500 to 600 measures of cofiEee per day; scores of anemics told me they could pick only from 100 to 250 measures per day. According to esti- mates given me by the managers of a number of large haci- endas in Porto Rico, the disease has reduced the average effi- ciency of the labor on these plantations to from 35 to 50 per cent. Dr. William M. McDonald reports that the disease is "sapping the life and energy of the population of Antigua." Dr. Parker, of Ecuador, says : "Last fall I visited one of the largest cocoa plantations near Babahoyo and found that the anemias of hookworm and chronic malaria made available not more than 33 per cent of work of the 300 laborers on that place." Dr. E. Brimont reports: "The disease has greatly retarded the development of French Guiana." The report THS ADMINISTRATIVE SECRETARY. I3 from British Guiana says: "The economic loss due to hook- worm disease on the sugar estates is heavy. On one estate, where the laborers were treated on a large scale, the manager reported that 'the working power of the gangs had increased 100 per cent.' " The report from Colombia, after stating that the infection is among the miners and in abundant profusion throughout the agricultural sections, where the laborers on the coffee, sugar, rubber, tobacco, banana, and other plantations are seemingly all affected, says that "one of the greatest prob- lems with which the people of Colombia are confronted at the present time is that of the evils attendant upon the presence of hookworm infection." Dr. T. F. McDonald, of Queens- land, reporting conditions in the Johnstone River district, says that infection is present in every square mile of it, and that "it is sucking the heart's blood of the whole community." The Right Honorable the Earl of Crew, Secretary of State for the Colonies, in his dispatch on this subject to the Governor of Ceylon, says : "Having considered the reports from the several colonies, with the observations of the committee upon them, I recognize that the loss of labor caused by the prevalence of ancylostomiasis is very serious, and affects prejudicially not only the employers of labor, but the community at large. Not only is there serious loss of life, direct and indirect, but also through the invaliding of laborers the charges for hospital and pauper expenditures are largely increased." In 1908 Dr. Brad- don examined 2,000 sick Tamils on the rubber estates in Negri Sembilan, Malay States, and says "there was no single one of these coolies who was not affected by ancylostomiasis" ; "that 60 per cent of all coolies at work were in an advanced state of ancylostomiasis." Dr. Graham, reporting for Lower Perack, Malay States, says that more than 50 per cent of the 14 OUTtlNE STATEMENT BY entire population is infected and that the disease is of "great economic importance to the rubber industry." In our own country Dr. Herbert Gunn, special inspector for the California State Board of Health, in his report on hook- worm infection in the mines of that State, says : "There is no question that the general efficiency of the men is noticeably impaired. At one mine, employing about 300 laborers, it was stated that a reserve of about 25 men had to be available to replace those who, on account of sickness, did not appear for work. Quite a few of the men have to lay off every now and again to recuperate. Several who were unable to work stated that when they arrived in Jackson they were perfectly strong and well. A large number of these men were encountered on the streets, some of them presenting marked degrees of ane- mia. The greatest loss to mine operators is occasioned by the large number of those moderately afifected. * * * A loss of 20 per cent in efficiency of those infected would be a conserva- tive estimate. That would mean in Mine No. 2, for instance, where over 300 men are employed at an average of about $2.50 per day, and estimating the number of those infected as low as 50 per cent, a loss of over $20,000 a year." This estimate is for one mine. Dr. Gunn reports "that in- fection undoubtedly is present in practically all of the gold mines of California. Infection is present, also, among agri- cultural laborers of that State. But the infection in California is light as compared with nine or ten of our South Atlantic and Gulf States, with their 20,000,000 of people. If an infection of 50 per cent in one gold mine employing 300 men causes a loss conservatively esti- mated at over $20,000 a year, what must be the economic sig- nificance of this disease for India, with its 300,000,000 of peo- ple and from 60 to 80 per cent of them infected ? THB ADMINISTRATIVS SECRETARY. 1 5 d. Retarding effect on education and civilization. — We have on file a photograph of a group of children, no one of whom until this year had ever been in a school ; no member of their parents' family, of their grandparents' family, or their great- grandparents' family on either side had ever gone to school. We have in this family a record of at least four generations of illiteracy due to the disabling effects of hookworm disease. In the community in which this family lives are many other fami- lies showing a similar history. I have visited many communities in which a large proportion of the children have been kept out of school by disability due to this cause. I have visited schools and have on file records of many others in which all or a large proportion of the children attending are infected. Rec- ords of the definite survey show in extreme cases an average infection among rur^l children of school age for whole coun- ties running as high as 70 to 90 per cent. The statement by Dr. E. Brimont, that "the disease has greatly retarded the development of French Guiana," is appli- cable even in greater degree to many other countries. Acute disease may strengthen a race by killing off the weak; but hookworm disease is chronic. It works subtly through long periods of time, and its cumulative results — physical, intel- lectual, economic, and moral — are handed down as an increas- ing handicap from generation to generation. The letter on page 119, showing the effects of the disease on one community, is a statement in concrete miniature of what it means in the large. This letter portrays a situation which for our States is extreme; but many countries, like Egypt, India, and China, have suffered a heavy infection for centuries, and its results have been handed down from generation to generation for ages as a cumulative handicap to the development of these people in all things that make for civilization. l6 OUTr,INB STATEMENT BY e. Spread of the infection by immigration. — It is estimated that from 60 to 80 per cent of the total population of India are infected. Every country importing coolie laborers from India is bringing on to its own soil a heavy stream of infec- tion. In Assam Dr. Bently examined 600 Indian coolies just arrived, and found only one of them free from infection. When the attention of the government at Durban was called to the heavy infection among the coolie laborers on the sugar estates of Natal in 1908, the authorities examined the next shipload of coolies from India and found 93 per cent of them infected. The Indian coolie is the chief source of labor supply for British Guiana; examination of all coolies arriving for the year 1909 showed an average infection of 74.44 per cent; this importation of coolie labor is regarded as the source of the present extremely disastrous infection in that country. About 16,000 Indian coolies have been imported into Jamaica, and it is estimated that 50 per cent of them are now infected. By the importation of coolie labor the infection has been car- ried and is being carried from India also into Dutch Guiana, Ceylon, the Federated Malay States, the Straits Settlements, and Java. The health authorities at San Francisco examined a shipload of Indian coolies just arrived at that port last year, found an infection of about 90 per cent, and established quar- antine against further immigration of this type. Every group of Indian coolies now in California is a center from which the infection is spreading in that State. From the outbreak of the disease in the St. Gothard tunnel the infection was carried into the mines of Austria, Belgium, and Germany. In these countries large sums have already been spent in a systematic effort for its eradication. These, among a multitude of similar facts, suffice to show THE ADMINISTRATIVE SECRETARY. 1 7 that hookworm disease, in the light of our present knowledge, has ceased to be a local matter ; it is an international problem of serious proportions. 2. Getting the people treated. — In getting the people treated, the work in each .State this year has followed two lines of effort: (i) Enlisting the physicians in the work. — The activities outlined in the report for 1910 have been kept up; the results are tabulated as a part of each State report and are summar- ized on page 68. Of the 21,244 practicing physicians in these nine States, 4,126 have reported treating the disease. The re- port from North Carolina shows that of the 1,879 physicians in that State, 1,195 are treating the disease. The physicians reporting as enlisted in the work have treated during the year 53,167 persons. (2) Getting the people to seek examination and treat- ment. — When the work began two years ago the people did not know hookworm disease as a disease. The announcement of its prevalence they had not taken seriously. It was ex- tremely difficult to induce them to be examined, and even more difficult to get them when found infected to consent to treat- ment. The physician could not treat them until they had been shown that it was to their interest to seek his aid. For two years systematic effort has been made to give- them the facts. The educational activities outlined in the report for last year have been persistently pursued in each State ; the people have been taught by public lectures with charts and lantern slides, by bulletins and folders, by the public press, by exhibits at State and county fairs, by the examination of children in the schools and students in the colleges, by examinations made at 2b l8 OUTUNE STATEMENT BY the State laboratories, by the celebration of public-health day ; and most effective of all has been the teaching of the people by demonstration through the treatment of large numbers at the county dispensaries. a. The county dispensary. — The county dispensary is a development of the present year. The first dispensary was opened by Dr. C. J. Cully, at Columbia, Mississippi, on Decem- ber 15, 1910, and was referred to in our annual report for the year as "the most promising move that has been made in the direction of supplying treatment for the indigent." In its sur- prising development during the present year we have almost ceased to think of it as a means of supplying treatment to the indigent in view of its incomparably greater value as an agency for teaching all the people by demonstration. The work of the county dispensaries in each State is con- ducted by members of the field staff under the general super- vision of the State director of sanitation for the State depart- ment of health ; all local expenses are borne by county funds. The work in a given county continues from 6 to 8 weeks; it is intensely educational from beginning to end; it reaches the entire population of the county, reaches over into the adjoin- ing counties, and makes its influence felt on the State as a whole. When the physician in charge goes into a new county to open up the work, the way has been prepared for him; the people in this new county have heard of what has been done in the adjoining county; a personal letter has been sent from the central office to the physicians and county officials calling attention to the work and asking that the State board's repre- sentative be given cooperation; the field physician is armed with a letter from the commissioners' court in the county in THE ADMINISTRATIVE SECRETARY. I9 which he has just been working, stating what appropriation this court had made for the work and what had been accom- plished ; he has also a letter from the physicians in the county in which he has been working, stating what the work has done for the people and how it has increased their own practice in treating the disease. With this preparation the work, for the county begins. (a) Getting cooperation of physicians. — The field director visits each physician in the county and gets him to sign a reso- lution endorsing the plan of work for the county and pledging his cooperation. The physicians as a rule give both moral support and active cooperation. On a recent visit to a dispen- sary my attention was called to a physician who had treated only 4 cases of hookworm disease before the opening of the dispensary in his county; on the day before my visit he had treated i6 cases in his regular practice. Recent report from one county shows that while the physician in charge of the dispensary treated little more than i,ooo people in about 4 weeks, the physicians of the county to a man engaged in the work treating with him during the same period 1,200 people. (b) Getting county appropriation. — The physician in charge presents a petition to the county commissioners asking that they make an appropriation from county funds to defray all local expenses, as for drugs, for printing, for the services of a microscopist, for local travel, etc. This petition is backed by the county medical society, the county school board, and by influential citizens. This appropriation of county funds by the county commissioners carries with it a moral weight which no appropriation of money from the outside could have ; it is an official announcement to every citizen that hookworm infec- tion is prevalent in the county; that it is a serious menace to 20 OUTLINE STATEMENT BY the public welfare; that cooperation in this relief work is a public duty. In Mississippi, Alabama, and North Carolina, where the dispensaries got the earlier start, the work has gained such momentum that many counties now take the initia- tive in making the appropriation, then ask the State board of health to send a representative to take up the work. (c) Tour of inspection and education. — The appropriation made or guaranteed, the field physician makes a tour of the county ; he inspects the schools and lectures to them ; he gives public lectures with stereopticon at important centers; he in- terests the newspapers and supplies them with copy and with cuts to illustrate it; he visits the mayors and other municipal officers and leading citizens in the towns, creating sentiment , and organizing support for the work. (d) Opening dispensaries. — The physician in charge selects usually about five points in the county for the dispensaries. These are centers to which the people may come for free ex- amination and treatment for hookworm disease. For each dispensary he fixes a day in the week on which it will be open for about six successive weeks ; he then floods the county with press notices, circular letters, and posters carrying this infor- mation to the people. (e) Treating the people and teaching them by demonstra- tion. — The physician visits each dispensary on the day set apart for it, and with the aid of a microscopist gives exami- nation and treatment to all who come. Marked cases are treated on clinical diagnosis; the doubtful ones are examined microscopically. Those found infected are given the drug in dose form in an envelope on which are printed directions for taking the medicine and sanitary directions for the prevention THE ADMINISTRATIVE SECRETARY. 21 of reinfection. A record is made of each case (see dispensary form, Exhibit yy). At the close of the work in the county the physician in charge makes to the county commissioners a report showing the expenditures, the work done, and the results accomplished. This report is published in the county, and is frequently given to the press of the State for its educational effect (see Ex- hibits 14, 15, and 16). When the work began two years ago the State directors and I were strongly of the opinion that the people would not come to dispensaries for examination and treatment. At times the clinics are small when the dispensaries are new or in com- munities where the infection is light; but in communities where the infection is heavy and after the dispensary has had a few days within which to demonstrate its effectiveness, the people come in throngs ; they come by boat, by train, by private conveyance for 20 and 30 miles. Our records contain stories of men, women, and children walking in over country roads ID, and 12 miles, the more anemic at times falling by the way, to be picked up and brought in by neighbors passing with wagons. As many as 455 people have been treated at one place in one day. Such a dispensary group will contain men, women, and children from town and country, representing all degrees of infection and all stations in life. A friend who had just visited some of the dispensaries said to me recently : "It looks like the days of Galilee." The people usually begin to arrive early. I visited one dis- pensary at 8 o'clock in the morning and found 43 persons there waiting for attention. They linger; they gather in groups around the tables of exhibits; they listen to the stories of improvement as told by those who have been treated, and 22 OUTUNE STATEMENT BY return to their homes to report to their "neighbors what they have seen and heard. The rapidity with which this teaching by demonstration gets its hold upon the people in communities where the infection is heavy is seen in the early records of the work in new territory. When the work opened in North Carolina in July, Dr. Covington treated in Halifax county the first week 194 people; the second week, 438; the third week, 537. In Robeson county Dr. Page treated the first week 40; the second week, 185 ; the third week, 478. In Sarnpson county Dr. Strosnider treated the first week 53 ; the second week, 316; the third week, 926. Four men in the first week of the work treated 615 cases; in the fourth week they treated 2,808. Dispensaries are now in progress in North Carolina, South Carolina, Georgia, Alabama, Louisiana, Mississippi, and Ten- nessee. Some work has been done in Virginia, and three counties in that State have made the appropriation. In North Carolina 27 of the 100 counties have made the appropriation since July i ; in South Carolina 8 counties have made the appropriation; in Georgia, 2; in Alabama, 14; in Louisiana, 9; in Mississippi, 13; in Arkansas, i ; in Virginia, 5; in Ten- nessee, 5. In the 9 States 85 counties have appropriated $10,- 799.60 for the work. The work has been organized in 66 counties, and 74,005 persons have thus been treated. b. Results. — The effect of these educational activities is seen first of all in the transformation which has been wrought in public sentiment. This change of sentiment shows itself in the cooperation of the press — which is now practically uni- versal in all the States — in the growing cooperation of the physicians, of the educational agencies, of the whole people ; it shows itself in an increasing support, not only of this particu- lar work, but of all public-health interests. Dr. Leathers, in THE administrative; secretary. 23 reporting for Mississippi, says: "The attitude of the public relative to public-health work is wholly different from what it was beginning with June i, 1910; the State Medical Associa- tion has been awakened as never before in behalf of medical legislation. The incoming- legislature unquestionably has a more intimate knowledge of the needs of the State along public-health lines than during any previous session of the State Legislature. * * * Public sentiment has been bettered to the extent of, I should say, 70 per cent." An expression of this growing sentiment is seen in the appropriations for the county dispensaries and in the records of examinations and of persons treated. Q. . Microscopic examinations, ^'"*- 1910. 1911. Alabama 92 2,640 Arkansas 442 3,460 Georgia 1,165 7,8i6 Kentucky 834 Louisiana 79 5,975 Mississippi 1,682 14,757 North Carolina 7,949 37,328 South Carolina 85 3,052 Tennessee 545 7,876 Virginia 2,750 6,986 14,749* 90,724 Total number microscopically examined 105,473 * This number represents the microscopically positive for igio. There were probably a few more examinations made but there is no definite record of other examinations. 24 OUTLINli; STATEMENT BY Persons treated. State. , * V igio. 1911. Alabama 23,359 Arkansas 3.330 1.787 Georgia 1,400 8,200 Louisiana 9.429 Mississippi 824 35.099 North Carolina 8,000 45,88r South Carolina 665 5,020 ' Tennessee 204 2,735 Virginia 8,868 Total 14,423 140,378 Total persons treated to date. ... 155.301 3. Educating the people in sanitation. — All our work — even the treatment of the people — is educational; every per- son treated becomes the teacher of his neighbors; the final aim of all our effort is to teach the people to stamp out hook- worm infection by putting a stop to soil pollution. To this end three lines of activity are specifically directed : (i) The sanitary survey. — The preliminary sanitary survey as conducted last year lacked uniformity and definiteness. In February of the present year the State directors in conference in Atlanta agreed upon a uniform plan for a definite sanitary survey of all the States. The survey is based on privy con- ditions and is to determine the degree of prevention of soil pollution. All privy types in use in these States were classi- fied under the heads of "A," "B," "C," "D," "E," and "F" types; to each type was assigned its rating of efficiency on a scale of 100. The survey is made by counties; it is based on THE ADMINISTRATIVE SECRETARY. 25 an inspection of at least loo rural homes; the number of homes inspected usually runs from 200 to 700 for the county ; the inspector while on the ground records the privy conditions as of the A, B, C, D, E, or F type- When the inspection is completed the sanitary index for the county is estimated as follows : County. 1 at 75 per cent (Class B) 75 2 " 25 per cent (Class D) 50 165 " 10 per cent (Class E) 1,650 58 " o per cent (Class F) 00 226 ) 1,175 7 19/22 Sanitary index for the county 7 19/22 This means that the sanitary index for this county is in round numbers 8 on a scale of a possible 100. The results of this survey as they come in are being tabu- lated and mapped by counties'. It is giving us a body of defi- nite information on soil pollution in rural districts. The work has been completed for 125 counties in nine States. A total of 43,448 rural homes have been inspected; of these 21,308 have no privies. (2) Teaching the people the danger of soil pollution and how to stop it. — The infection survey is giving a pretty defi- nite index to the degree of infection for each county; the sanitary index is giving definite information on the sanitary conditions responsible for the presence and spread of the dis- ease; the work of the physicians and the county dispensaries is demonstrating what the presence of this infection means to 26 OUTLINE STATEMENT BY the individual and to the community ; the organization in each state is driving these facts home to the people. Every activity outlined in detail in the report for last year has been kept up with increasing volume and definiteness ; the people are being taught by public lectures illustrated with photographs, charts, and stereopticon ; by bulletins and folders ; by the public press ; by exhibits at State and county fairs; by definite instruction in sanitation in the schools. During the year the State organizations have delivered 3,620 public lectures; have reached in this way 451,877 people; have reached by personal visit 673 newspapers and furnished 1,843 articles to the press; have reached by personal visit 9,450 teachers, by bulletins 43,393, by letters 17,294, by lectures at institutes 15,448; they have distributed to the people 908,436 bulletins on sanitation. (3) Improving the county health service. — The successful accomplishment of this task rests upon four permanent agen- cies : the State department of health, effectively organized and adequately equipped to give the work permanent organization and supervision; the practicing physicians of the State so en- listed in the service that they can be depended upon to treat all persons infected; the State system of public schools giving definite instruction in sanitation as a regular and permanent part of the school work ; and, finally, in each county a capable county superintendent of health devoting his whole time to public-health work. At present the county health officer in most counties in this country is a practicing physician; he is paid an insignificant sum to look after the public-health interests of the county, but must depend for the support of himself and his family on his private practice ; it is not his fault that the service is in- THE ADMINISTRATIVE SECRETARY. 2/ effective. The work is not going to be done until the man is paid an adequate salary for his services and is required to devote his whole time to the work.* The last legislature of North Carolina enacted a law author- izing the counties to appoint a superintendent of health for his whole time, and providing that a superintendent of health ap- pointed for his whole time shall, in addition to his other duties, make a sanitary inspection of all school plants, make medical examination of public-school children, and have microscopic- ally examined all children suspected of having hookworm dis- ease. This law became effective in February of this year. In June the county board of health of Guilford county, North Carolina, appointed a superintendent of health, appropriated $2,500 from county funds for his salary and expenses, and stipulated that he should give his whole time to the work- This ofRcer began work July i ; since that time he has inspected all the schools; has made a remarkable demonstration in the control of typhoid fever ; is getting an accurate record of vital and mortuary statistics ; is pushing disinfection of houses into the country and putting country springs, wells, and premises in sanitary condition ; is preparing to make a complete sanitary survey of the county ; is giving medical inspection to children in the rural schools; is conducting a continual campaign of education by means of stereopticon lectures ; and is publishing a leaflet that goes to every farm home in the county. Two counties in North Carolina now have superintendents of health giving their whole time to the work; the State re- ports increased efficiency in the health service of Columbus, Moore, Brunswick, Pender, Pitt, and a number of other coun- ties; the North Carolina State Board of Health is deeply in- * State Systems of Public Health in Twelve Southern States, p. 67. 28 OUTLINE STATEMENT OF terested in extending the service. Mississippi reports that at least 60 per cent of the county health officers of the State are more actively interested in public-health work. Definite sentiment has been created in Georgia in favor of a bill looking toward an efficient county health service. The bill enacted by the Arkansas legislature provided for a county health service.* The Kentucky State Department of Health, in taking up the work against hookworm disease, is undertaking to enlist the cooperation of county health officers in this work and to use it to create sentiment that will demand a superintendent of health for his full time. Observation of the work in Guilford county convinces me that with an effective county superintendent of health devot- ing his whole time to the work in any county, there is no reason why hookworm disease should not within reasonable time be stamped out and kept out, as it has been eradicated in Switzerland and Hungary and is being kept out of these coun- tries by the rigid observance of a few preventive measures. * This bill was lost from the clerk's desk after its passage and did not reach the Governor. CHAPTER II. SUMMARY OF ACTIVITIES AND RESULTS BY STATES. ALABAMA. I. State survey by counties. 1. Infection survey, — ^based oh an examination of at least 200 children between the ages of 6 and 18 years, taken at random from the country : County. Area. Population. No. examined. Geneva 662 22,230 613 Dale 654 21,608 227 2. Sanitary survey, — based on an inspection of privy conditions at, at least, 100 country homes : Total No. County. - inspected. Coffee 414 Dale 337 Dallas 555 Escambia 205 Greene 421 Perry 308 Pike 267 II. Getting the people treated. 1. Enlisting the physicians : Total. (1) Number of physicians in State 2,200 (2) Number of physicians personally visited 227 (3) Number of lectures to physicians 22 (4) Number of physicians reached 294 (5) Number of circular letters sent to physicians 1,200 (6) Number of physicians treating disease 227 (7) Number of persons treated by physicians 3,870 2. Getting the people to seek examination and treatment : (i) Number of schools inspected 261 (2) Number of school children examined 6,527 (3) Number examined at dispensaries 27.404 (4) Number of persons examined : Clinically 33,931 Microscopically 2,640 Positive '. 1,355 29 3" ALABAMA. (5) Total number of persons examined 36,S7i (6) Number of persons treated by field force 19,489 (7) Total number treated on record 23,359 3. Work of county dispensaries : County. Amount of appro. Butler . . . . Choctaw . . Coffee .... Conecuh .. Covington Dale Dallas.;.., Escambia . Geneva . . . Greene . . . Houston . . Perry Pike Sumter . . . Totals. $150.00 150.00 75-00 150.00 150.00 150.00 250.00 150.00 150.00 150.00 60.00 150.00 150.00 150.00 $2,035.00 Number persons and times treated. Total No. County. One. Butler 2,744 Choctaw Coffee 3,951 Conecuh 1,092 Covington .... 2,504 Dale 1,315 Dallas 667 Escambia 996 Geneva 1,459 Two. Three. Greene Houston Perry .. . Pike .... Sumter . 140 576 928 3,117 ISO 1,210 75 125 351 86 231 82 42 20 188 932 350 6S 336 Duration of campaign 6 weeks Not opened 11 weeks 7 weeks 8 weeks 7 weeks 8 weeks S weeks II weeks 3 weeks 7 weeks 5 weeks 5 weeks Not opened 83 weeks Total No. Total No of people of treat- treated, ments. 2,744 2,894 3,951 S.Sii 1,092 1,167 2,504 2,629 1,31s 1,666 667 753 996 1,292 1,459 1,541 140 182 576 596 928 1,116 3,117 4,38s Totals... 19,489 3,492 751 19,489 23732 4. Work of laboratory: (1) Number of specimens received and examined.... 335 (2) Number of specimens positive, hookworm ova.. . 117 (3) Percentage of infection thus shown 35 5. Summary: (i) Number of persons examined 36,571 (2) Number of persons treated by physicians. .. 3,870 (3) Number of persons treated by staff 19,489 (4) Total persons treated 23,359 AI^ABAMA. 31 III. Educating the people in sanitation. 1. By public lectures : (i) Number of public lectures delivered 161 (2) Estimated number of persons thus reached 15,000 (3) Total number of lectures delivered : Dr. Perry 165 Dr. Orr 230 Dr. Perdue 137 2. Through the schools : 532 (i) Number of teachers in State 6.434 (2) Number of teachers reached by visit 361 (3) Number of teachers reached by letter 380 (4) Number of teachers reached by bulletins 410 (5) Number of teachers reached by institutes 100 (6) Total number of teachers reached : Dr. Perry 377 Dr. Orr 407 Dr. Perdue 366 3. By bulletins, leaflets and special literature : I>IS0 (1) Total number bulletins distributed: Dr. Perry 24,000 Dr. Orr 30,000 Dr. Perdue 17,000 71,000 4. By the public press : Total. (i) Number of papers in State 258 (2) Number of papers personally visited 19 (3) Number of articles furnished for publication. ... 49 IV. Notes on the work of the year. I. Dothan city administration and the county board of health have been brought into a closer relationship, resulting in a more efficient and vigorous sanitary caijipaign. The salary of the city health officer for Dothan was raised from $200 to $400 per year. The city of Columbia raised by popular sub- scription $6,000 for the purpose of installing a modern sewer system. The town of Ozark floated bonds for a sanitary sys- tem. The city of Enterprise adopted regulations restricting the use of surface privies and providing means for handling them. A plan for a sewage system for the city has been made and the question of installing it is to be submitted to popular 32 ALABAMA. vote. The sewer area of the city of Troy is being extended. Sanitary regulations for the whole city are being more rigidly enforced. 2. The school authorities of Dale county adopted regulations requiring sanitary privies to be built at all schools and enforc- ing strict sanitary regulations. The community of Farmers' Academy, Cofifee county, has made arrangements for install- ing sanitary privies at the school and in most of the homes. Sanitary privies are now being built in the public schools in Pike county. 3. The county health officers in Perry county and- Greene county agreed to personally conduct a free clinic at their re- spective offices on Saturday of each week to treat, for hook- worm disease, all persons who would apply. The field man in each case advertised this fact over the entire county by means of circular literature and the county press. The two health officers supplemented this by mailing post cards stating their intention to continue the dispensary and urging the people to come for examination and treatment. The central office has given every possible aid to this movement in an effort to make it a success. 4. The one important result thus far achieved is one quite difficult to tabulate or to express in tangible terms, namely, the fact that there has been created a strong and active senti- ment 'arnong all sorts and conditions of men, women, and children as to the importance of hookworm eradication. This is a force that is working slowly but surely, and which must lead ultimately to a proper enforcement of regulations and certain legislation on sanitation. Legislation must follow in the wake of the educational campaign, which is creating a sentiment looking to that end. ARKANSAS. 33 ARKANSAS. I. State survey by counties. 1. Infection survey, — ^based on an examination, of at least 200 children between the ages of 6 and 18 years, taken at random from the country: Area in Number County. square miles. Population, examined. Bradley 658 9,651 260 Calhoun 646 8,539 210 Columbia 846 22,077 620 Cleveland.. 581 11,620 215 Dallas 657 11,518 260 Grant 640 7,671 250 Hot Spring 631 12,748 220 Ouachita 742 20,892 300 Union 1,074 22,495 350 2. Sanitary survey, — based on an inspection of privy conditions at, at least, 100 country homes : Total number County. inspected. Ashley 878 Bradley 670 Calhoun 286 Clark 740 Cleveland 468 Columbia 593 Dallas 440 Drew 570 Grant 740 Hot Spring ■ 404 Nevada 37o II. Getting the people treated. i 1. Enlisting the physicians: (1) Number of physicians in State 3,600 (2) Number of physicians personally interested 675 (3) Number of lectures to physicians 49 (4) Number of physicians thus reached 750 (5) Number of circulars and letters sent to physicians. 7,500 (6) Number of bulletins sent to physicians 5,000 (7) Number of physicians now treating the disease 200 (8) Number of persons treated by physicians 1,500 2. Getting the people to seek examination and treatment : (i) Number of schools inspected 222 (2^ Number of families inspected 7,800 (3) Number of persons examined clinically 4,000 3b 34 ARKANSAS. (4) Number of persons examined microscopically 3.460 Positive 1,879 (5) Total number of persons examined 7,460 (6) Number of persons treated by field force 287 (7) Total number of persons treated on record 1,787 3. Work of county dispensaries : County. ^I^lf ^"'^tZn^ Expenditures. ■" appro. campaign. "^ Columbia $50.00 Sweeks $50.00 No. persons and times treated. Total No. Total No. County. / ' > people treat- One. Two. Three. Four. treated. ments. Columbia 287 185 55 10 287 537 4. Report of laboratory: (1) Total number of specimens examined 1,601 (2) Number containing hookworm ova (3) Number containing other iparasites (4) Average per cent of infection 72 (5) Number of mailing cases distributed 2,000 (6) Number of mailing cases returned 1,400 5. Summary: (i) Number of persons examined 7,460 (2) Number of persons treated by physicians. . . 1,500 (3) Number of persons treated by staff 287 (4) Total persons treated 1.787 III. Educating the people in sanitation. 1. By public lectures : (1) Number of public lectures delivered 337 (2) Estimated number of persons reached 50,550 2. Through the schools: (1) Number of teachers in State _. 9,522 (2) Number of teachers reached by visit 805 (3) Number of teachers reached by letter 5,400 (4) Number of teachers reached by bulletin 5,40O (5) Number of teachers reached at institutes 1,600 3. By bulletins, leaflets, and special literature: (1) Total number of leaflets and bulletins distributed. . 61,324 4. Through the press : (i) Number of papers in State 310 (2) Number of papers personally visited 35 (3) Number of letters to press 360 (4) Number of articles furnished for publication..... no ARKANSAS. 35 IV. Notes on the work of the year. 1. There is a growing cooperation on the part of the press, the school teachers, the ministers, and the people. Many county papers have begun the publication of notes or articles dealing with health matters. Many of the ministers are preaching health sermons. The people are beginning to de- mand the passage of sanitary laws. 2. The recent legislature enacted a public-health law which gave to the Commissioner of Health all necessary power to make and enforce sanitary rules and regulations. The bill contained a special section which referred to rural sanitation and which was far-reaching in its aims. By some means the bill was lost before reaching the Governor for his signature; it therefore failed to become a law. The people of the State, having seen the work which has been done by the Rockefeller Commission, are in favor of a public-health department, and it is confi- dently expected that the ill-fated bill will be enacted at the next meeting of the legislature. 3. The State Teachers' Association, at its annual meeting December 28 to 30, took official action, organizing in each county a county school bureau of health. The purpose of this bureau is to enlist the cooperation of the entire teaching pro- fession in an organized movement to improve sanitary condi- tions at the schools and at the homes throughout the State. This action brings to the work the cooperation of 9,000 teach- ers for the year 1912. 36 GEORGIA. GEORGIA. I. State survey by counties. 1. Infection survey, based on an examination of at least 200 children between the ages of 6 and 18 years, taken at random from the country: Area in Number County. sq. miles. Population. examined. Lowndes , 455 20,036 219 Tift 349 2. Sanitary survey, based on an inspection of privy conditions at, at least, 100 country homes : Total No. County; inspected. Clarke 726 Berrien 370 Gwinnett 226 Hall 398 Jackson 208 Madison 686 Oconee 565 Tift 299 Turner 425 Walton 35° Washington " 728 II. Getting the people treated. 1. Enlisting the physicians : (1) Number of physicians in State 2,887 (2) Number of physicians personally interested. . . 613 (3) Number of lectures to physicians 11 (4) Number of physicians thus reached 429 (5) Number of letters and circulars sent to physi- cians 2,887 (6) Number of bulletins sent to physicians.. 2,887 (7) Number of physicians now treating the disease 690 (8) Number of persons treated by physicians 7>228 2. Getting the people to seek examination and treatment : (i) Number of schools inspected 4S4 (2) Number of persons examined clinically 28,932 (3) Number of persons examined microscopically. 7,816 (4) Total number of persons examined 36,748 (5) Number of persons treated by field force 972 (6) Total number of persons treated on record. . . . 8,200 GEORGIA. 2>7 3. Work of county dispensaries: County Amt. of Duration of ^' appro. campaign. Lowndes $150.00 6 weeks Tift 150.00 6 weeks Totals $300.00 12 weeks No. persons and times treated. Total No. Total No. County. < ' ^ of people of treat- One. Two. Three. Four. Five, treated. ments. Lowndes 385 78 9 4 i 385 477 Tift 587 33 3 •• •• 587 623 Totals 972 III 12 4 I 972 1,100 4. Work of laboratory: (1) Number of examinations positive 1,877 (2) Number of examinations negative 2,423 (3) Total number of examinations 4,300 (4) Number of specimens of hookworm 1,877 (5) Number of specimens of Taenia 57 (6) Number of specimens of Trioccephalus Dispar.. 2 (7) Number of specimens of Ascaris lumbricoides. .. 39 (8) Number of specimens of Oxjruris vermicularis . . . 5 . (9) Total number intestinal parasites 1,980 Summary : (1) Number of persons examined 36,748 (2) Number of persons treated by physicians. 7,228 (3) Number of persons treated by staff 972 (4) Total number of persons treated 8,200 TIT. Educating the people in sanitation. 1. By public lectures: (1) Number of public lectures delivered ..-. 631 (2) Estimated number of persons thus reached. '......' 50,772 2. Through the schools : (1) Number of teachers in State. 8,714- (2) Number of teachers reached by visit 845' (3) Number of teachers reached by bulletin ' 7.500 (4) Number of teachers reached at institutes .; 850 3. By' bulletins, leaflets, and special literature : * (1) Number of bulletins, leaflets, etc. 39,275 (2) Health talks by State Director and sent to teach- ers by Superintendent of Education ,. ; . . l,50t> (3) Typewritten plans of sanitary surface privy 173 38 GEORGIA. (4) Plans of surface privy sent from Dept. of Educa- tion. . . ., i.Soo (5) Two letters to Congressmen urging distribution of Department of Agriculture Bulletin 463 22 (6) Literature distributed by field men 25,417 (7) Literature distributed by central office 43.502 (8) Total literature distributed 68,919 4. Through the public press : (i) Number of papers in State 37S (2) Number of papers personally visited 81 (3) Number of letters to press 295 (4) Number of articles furnished for publication 655 (5) Number of articles printed for field men loi IV. Notes on the work of the year. 1. The State Board of Health has granted permission to the Department of Field Sanitation to undertake dispensary work, provided the consent of every practicing physician in counties where the work is to be done is first secured. 2. There are no county boards of health in Georgia. 3. The County Board of Education in Bartow has issued regulations requiring sanitary privies at all the schools in the county. The Lowndes County Board of Education is urging the installation of sanitary privies in the rural schools of the county. 4. The press is more active in its campaign for better health and sanitary conditions than ever before; the relationship be- tween the Department of Health and the Department of Edu.- cation is closer than ever before. There is a growing coopera- tion on the part of the people. 5. For the Department of Education we have prepared plans and specificatioils for sanitary privies at public schools and a bulletin on health talks for use in the public schools. 6. The Governor issued a proclamation calling for a Health Day, with proper ceremonies, at the public schools. 7. Our work helped to secure medical inspection of school children in Fulton county and Decatur. LOUISIANA. 39 LOUISIANA. I. State survey by counties. 1. Infection survey, — based on an examination of at least 200 children between the ages of 6 and 18 years, taken at random from the country : Parish. Acadia Bienville Caddo Lafayette Lincoln St. Martin St. Tamriiany Union Vermilion Washington Vrea in Number are miles. Population. examined. 633 23,483 283 832 17,588 548 906 44,499 205 259 22,82s 267 46s 15,898 558 493 18,940 352 874 13,335 304 888 18,530 221 1246 20,705 398 638 9,628 502 2. Sanitary survey, — based on an inspection of privy conditions, at, at least, 100 country homes : Total No. Parish. inspected. Acadia i,349 Bienville 662 Caddo 205 Lafayette 726 Lincoln 467 St. Martin 851 St. Tammany 387 Union 475 Vermilion 817 Washington 546 II. Getting the people treated. 1. Enlisting the physicians : (1) Number of physicians in State 2,033 (2) Number of physicians personally interested 791 (3) Number of lectures to physicians 12 (4) Number of physicians thus reached 696 (5) Number of circulars and letters sent to physicians. 6,500 (6) Number of bulletins sent to physicians 4,627 (7) Number of physicians novf treating disease 159 (8) Number of persons treated by physicians 1,197 2. Getting the people to seek examination and treatment : (i) Number of schools inspected 431 (2) Number of persons examined clinically 28,978 (3) Number of persons examined microscopically. . . . 5,975 (4) Total number of persons examined 34,953 (5) Number of persons treated by field force 8,232 (6) Total number of persons treated on record 9,429 40 LOUISIANA. 3. Work of county dispensaries: Amt. of Parish. appro. Bienville f 100. 00 Caddo 150.00 Jackson 150.00 Lincoln 100.00 Morehouse 200.00 Rapides 100.00 St. Tammany 150.00 Union 100.00 Washington 100.00 Duration of campaign. 6 weeks Running. Not begun. 6 weeks Not begun. Not begun. 6 weeks Running. 6 weeks Parish. Totals $1,150.00 24 weeks Number of persons and times treated, Expendi- tures. $100.00 127.50* 75.00 100.00 $402.50 One. Two. Three. Four. Five. Six. Bienville 1183 185 68 54 Caddo Jackson Lincoln 1481 Morehouse Rapides St. Tammany 715 Union Washirjgton 1622 215 52 29 261 741 Totals 5001 1402 4. Work of laboratory : 60 341 521 Train Field men . . . Central office Number of examinations. 229 4532 1021 5782 II 27 121 Positive. 104 1 70s 128 Total No. Total No. people of treated, treatments. 1 183 1481 71S 1622 5001 1490 1779 1047 2733 7049 Negative. Per cent. 1937 125 2827 893 384s 45-4 37-6 12.5 5. Summary: (1) Number of persons examined 23,598 (2) Number of persons treated by physicians i,i97 (3) Number of persons treated by staff 8,232 (4) Total number of persons treated 9 429 III. Educating the people in sanitation. I. By public lectures : (1) Number of public lectures delivered 466 (2) Estimated number of persons thus reached. . .•. 97,237 ♦School Board will pay balance of $27.50. I.OUISIANA. 41 2. Through the schools: (i) Number of teachers in State 4,981 (2) Number of teachers reached by visit 1,760 (3) Number of teachers reached by letter 2,378 (4) Number of teachers reached by bulletins 4,000 (5) Number of teachers reached by institutes 2,277 3. By bulletins, leaflets and special literature: (i) Total number distributed 62,027 4. Through the public press: (i) Number of papers in state 219 (2) Number of papers personally visited 104 (3) Number of letters to press 1,200 (4) Number of articles furnished for publication 150 IV. Notes on the work of the year. 1. Regulations were adopted by State Board of Health re- quiring Stiles' sanitary privy as a minimum. The Secretary has notified all superintendents of the various parishes that the law concerning closets at the schools must be complied with. The State Board of Education is backing the regula- tion of the State Board of Health. Superintendent Harris has requested reports on school closets from parish superin- tendents and. is backing the regulation of the State Board of Health. 2. Haynesville has a law requiring the installation of sani- tary closets in all homes. The authorities established a closet license of 40 cents per month, the town assuming the task of remodeling all closets to conform to the law. Janesville and '^earl River have adopted laws requiring sanitary closets. The citizens of Opelusas voted a tax for sewage system. 3. Lincoln parish adopted resolutions endorsing the sanitary work now going on in the State for the eradication of hook- worm disease and pledged themselves to the improvement of sanitary conditions at the public schools. St. Tammany, La- 42 LOUISIANA. fayette, Tangipahoa, and St. Martin adopted regulations re- quiring sanitary closets in all schools. Estimated number of sanitary privies built, 1,500. 4. The health officer of St. Tammany parish has agreed to continue the free treatment of patients after the regular cam- paign closes, doing this work on Saturdays. The parish made an appropriation of $75 to continue the free treatment for hookworm disease. The health officer of Washington parish has also agreed to continue the free treatment of patients for hookworm disease. 5. The Louisiana State Medical Society at its annual meet- ing in Shreveport adopted resolutions approving the work of the campaign to eradicate hookworm disease; the Society pledged itself to cooperate and urged upon the police juries of the different parishes and the medical profession in Louisi- ana the necessity of community action; it recommended that appropriations be made for the dispensary work. MISSISSIPPI. 43 MISSISSIPPI. I. State survey by counties. I. Infection survey, based on an examination of at least 200 children between the ages of 6 and 18 years, taken at random from the country : Area in County. ■ square miles. Alcorn Clarke Covington . . . George Harrison. . . . Itawamba . . . Jefif Davis.. Jones Lafayette. . . . Lincoln Marion Newton Pearl River. Rankin Scott Simpson Tishomingo. 402 064 577 982 526 674 673 574 1.095 S6i 663 774 584 578 433 Population. 14,987 17,741 13,076 21,002 13,544 17,846 22,110 21,552 23,501 19,708 6,697 20,955 14,316 12,800 10,124 Number examined. 208 215 S08 902 219 347 283 1,108 199 1.333 1,472 541 395 435 542 482 372 2. Sanitary survey, based on an inspection of privy conditions at at least 100 country homes. County. Alcorn Itawamba . . , Jones Lamar Leake Marion Pearl River Smith Tishomingo . Total number inspected. 514 351 139 140 250 300 234 ■ 239 261 II. Getting the people treated. Enlisting the physicians: (1) Number of physicians in State 1,783 (2) Number of physicians personally visited i,35o (3) Number of lectures to physicians 16 (4) Number of physicians thus reached 831 Xs) Number of circular letters sent to physicians 5,835 (6) Number of bulletins sent to physicians 21,336 (7) Number of physicians treating the disease 786 (8) Number of persons treated by physicians 15,803 44 MISSISSIPPI. 2. Getting the people to seek examination and treatment : (i) Number of schools inspected 571 (2) Number of persons examined clinically ._ 21,194 (3) Number of persons examined microscopically. I4,7S7 (4) Total number of persons examined. 3S.95I (5) Number of persons treated by field force 19,296 3. Work of county dispensaries: County. George Harrison . . . Jackson .... Jones Lamar Lincoln Leake Marion Neshoba . . . Pearl River Scott Tishomingo Winston . . . . Amt. of Co. app. 150.00 150.00 150.00 158.10 150.00 200.00 225.00 181.50 150.00 150.00 100.00 150.00 200.00 Duration of campaign. Running 6 wks. 4 das. Running 9 weeks 6 weeks Running S weeks S months 5 weeks 4 wks. 3 das. 3 weeks 5 weeks Running Totals. $2,114.60 County. Number of persons and times treated. One. Two. Three. Four. Five. Six. George 997 869 653 278 5 o Harrison 2621 1973 1464 820 64 6 Jackson Jones 2532 1462 896 103 Lamar 1583 931 456 29 Lincoln 671 173 64 o 180 462 64 weeks. Total No. Total No. people of treated, treatments. 997 2802 2621 6948 Leake 610 Marion 1078 14 168 Neshoba 1883 706 268 Pearl River 2480 1403 892 Scott 162 33 I Tishomingo 771 197 22 Winston 4 29 51 55 o I 2 4 o o 5 15 9 o o Totals ... 15388 8389 1370 104 2532 1583 671 610 1078 1883 2480 162 771 15388 4995 3003 908 808 1742 2923 4839 196 991 30155 4. Work of laboratory: (1) Total number of examinations 1600 (2) Number of examinations positive hookworm 500 (3) Number of examinations negative hookworm iioo (4) Parasites found: Necator Americanus 493 Hymenolepis nana j 20 Asearis' lumbricoides ; . . . : 8 MISSISSIPPI. 45 Agchylostoma duodenale . . .~ 7 Strongyloides intestinalis 5 Oxyuris vermicularis 2 Circoraonas intestinalis 2 Balantidium coli I Taenia saginata I Total 539 5. Summary: (i) Number of persons examined by State organization. 35,951 (2) Number of persons treated by physicians. ... 15 803 (3) Number of persons treated by staff 19,296 (4) Total number of persons treated 3S,009 III. Educating the people in sanitation. 1. By public lectures: (1) Number of public lectures delivered 302 (2) Estimated number of persons thus reached 51,640 2. Through the schools : (i) Number of teachers in State S,440 (2) Number of teachers reached by visit I.SOO (3) Number of teachers reached by letter 1,226 (4) Number of teachers reached by bulletins 5,440 (5) Number of teachers reached at institutes 3,760 3. By bulletins, leaflets and special literature : (1) Total number distributed 246,000 4. Through the public press: (i) Number of papers in State 258 (2) Number of papers personally visited ; 130 (3) Number of letters to press 150 (4) Number of articles furnished for publication 310 IV. Notes on the work of the year. I. The attitude of the public relative to public-health work is wholly diflferent from what it was beginning with June i, 1910. The State Medical Association has been awakened as never before in behalf of medical legislation. The incoming legislature unquestionably has a more intimate knowledge of the needs of the State along public-health lines than during any previous session of the State legislature. The legislature 46 MISSISSIPPI. convenes at noon on Tuesday, January 2, 1912. Five bills will be presented to the legislature for consideration, namely, "A bill amending the Medical Practice Act requiring a high- school training for the study of medicine and the M. D. degree from a reputable medical college before being admitted to the licensing examination for the practice of medicine"; "A bill requiring the reporting of births and deaths of the entire State"; "A bill making it possible for the building of sanitary closets at every school-house in the State"; "A bill legalizing the inspection of hotels, trains, railway cars, depots, and public buildings." 2. By a regulation of the State Board of Health the public drinking cup has been abolished during the past year on all trains of the State. This regulation is also applied to schools and public buildings. 3. The record relative to the building of sanitary closets as near as can be determined is five hundred. 4. Many towns and cities have passed regulations resulting from the campaign during the past year. Amory, Miss., voted the issuance of bonds to the amount of $60,000 for sewerage, largely the result of this work. Laurel, Miss., has passed an ordinance requiring sanitary closets and the safe disposal of waste. Lexington, Miss., has also passed such an ordinance. 5. I think it is perfectly conservative to state that 60 per cent of the county health officers of the State are more actively interested in public-health work. 6. Public sentiment has been bettered to the extent of, I should say, 70 per cent. 7. The public-health work during the past year has pro- gressed along all lines in a very satisfactory manner. There MISSISSIPPI. 47 has been a general awakening on the part of the people throughout the State in regard to better sanitary conditions about the home, around the school, and in all community life. Public sentiment has been aroused in behalf of the campaign for improved sanitary conditions. However, the problem of eradicating any disease is an enormous task, but with a con- tinuously aggressive and determined effort on the part of public-health officials within a relatively short time Mississippi, as well as the entire South, can be revolutionized in the protec- tion of human life by preventing not only hookworm disease, but also the other common preventable diseases. 8. In my opinion the Rockefeller Sanitary Commission has been instrumental in creating a movement throughout the South which will ultimately have its effect upon the entire country. It is undoubtedly a monumental undertaking and will result in untold and incalculable good to the South and to the entire country. 48 NORTH CAROLINA. NORTH CAROLINA. I. State survey by counties. 1. Infection survey, based on an examination of at least 200 chil- dren between the ages of 6 and 18 years, taken at random from the country: Area in JSTumber County. sq. miles. Population. examined. Burke, 400 21,408 426 Caldwell, 450 20,579 337 Columbus, 750 28,020 263 Cumberland, 900 35,284 1537 Davie, 500 13.394 225 Duplin, 670 25,442 257 Hertford, 340 15.436 389 Johnston, 740 41.401 394 McDowell, 440 13.538 287 Mitchell, 240 17.245 210 Montgomery, 570 14.967 248 Pender, 800 iS,47i 612 Pitt, 820 36,340 412 Randolph, 900 29,491 254 Robeson 950 Si.945 I4ii Rowan, 461 37,S2i 246 Sampson, : 921 29,982 859 Wake, ^^^ 63,229 200 Warren, 4S0 20,266 399 Wayne, 600 3S.698 i,943 Yancey, 400 12,072 557 2. Sanitary survey, based on an inspection of privy conditions at at least 100 country homes : Total No. County. inspected. Bladen, ^ 141 Brunswick, 336 Buncombe, 249 Burke, 36S Caldwell, 670 Catawba, 198 Chatham, 103 Cleveland, 359 Columbus, 78s Cumberland 294 Davidson, 143 Davie, Ill Duplin, 338 Edgecombe, I7S Forsyth, IS7 Gaston, 118 Greene, 240 Guilford, 208 Halifax 721 Harnett, ii9 Hertford, 183 NORTH CAROLINA. 49 Iredell, 265 Johnston, 249 Jones, 206 Lenoir, 312 Lincoln, 269 McDowell, 456 Mitchell, 597 Montgomery,. 329 Northampton, 357 Onslow, 473 Pender, 2ig Pitt, 260 Randolph, 283 Robeson 477 Rowan, , 350 Rutherford, 379 Sampson, 179 Stanly 107 Wake, , 133 Warren 444 Wayne, 211 Wilson, 187 Yancey, , 433 II. Getting the people treated. I. Enlisting the physicians : Total, (i) Number of physicians in State 1,879 (2) Number of physicians personally visited 676 (3) Number of lectures to physicians 11 (4) Number of physicians thus reached 300 (5) Number of circular letters sent to physicians. 7,061 (6) Number of bulletins sent to physicians 3,130 (7) Number of prescription pads 4,000 (8) Number of physicians treating disease : Number reporting 1910 838 Number of additional reporting 1911.. 357 Total number reporting 1,195 (9) Number of persons treated by physicians : 1910 8,000 1911 16,709 Total number of persons treated byphysicians 24,709 2. Getting the people to seek examination and treatment : Total ( 1 ) Number of schools inspected 470 (2) Number of persons examined : Clinically 47,289 Microscopically 37,328 (3) Total number of persons examined 84,617 (4) Number of persons treated by field force. . . . 29,172 4b so NORTH CAROLINA. _ « ■ o S 2 CO M lOt^ vo o o «^ « CO CO ■^ CO to to « 1 o ovo ■* o o o\ »-< -t- ~ M O CO w ^ "1 CM vS C _o vo i^m COt^CX) M Ov O in vn CO 0\ " ■* S CO , C a o O s 7S X + CO COOQ i VOOO N c « colv > 0> CO" P. MOO tT* com M '^ txvO o CO CO CO N + o WVO M Ovvo N Q vo ^-. " -^ lO m HH d tx^xcovo vo O. " CO CO IXVO M CO OV m t^"* Ov cOC>V O 00 PI vo •«fOO Ov s '1.2 S CO + ro CO l-s, rs. 1 TT ^ W W CO (N •o B V Q. U o a> I" ■*cooo < t^ O coo 0< PI 1-1 > cA CO tn c/1 oj a> a> u 4J u 0) u S & S S vovo mvo 5 3 5 3 CO COM N •s ^ w 8 ^ 01 CO c» S weeks weeks weeks vovo Oi 1 c 9 O o 3 •SI §1^ 888 CO CO CO B i; ^- BT^ 4j o Eh "2 'S u o E- -a c o. W B .£? '3 o< E E^^ Is .^ weeks weeks weeks weeks a: vo lOVOVO 5? 8888 O 3 B o V ^ m 00 VO t^W moo ovm tx O^ X Tf M dv ■^ •-'" * * # » VQ CO N VO CO CO ro Ti- ^ « to»n o i^ o Tt\0 CO w -^ OiMOO m N 00 o o o 0) --; 00 TtodoQ ■^ m CO -^ Cl HH M M M Q\ "^ Q\ O 000 OVM ^ 00 r^t^vo N s o U weeks weeks weeks weeks ■*■*■* tT m f/i ui m V 4J CJ (U s ? ? s ^ CO i-i covoOO 0) C^ N M o\ 4J ca O C 5? oj ti 88 §0000 O Q Q O O O\O00 m •a .3 ■« eg 3 2 mo Mi"- Oi5 (InWCUOffi O o CO 69- Ml ^_, OJ « 5 CO •*^ C w •S eS *^J3 O = 15 13 & •o _ " "73 •o c 1 iij"^ ! •« ^j ; .20 «5 . j_, « ■° o Ji K 5 o 6^.2 52 NORTH CAROLINA. Doctor and Number receiving treatment. county. I * \ One. Two. Three. Four. (Page) Robeson 1,973 * * * Cumberland . .. 1,839 477 89 24 Bladen 1,483 339 "9 5 Harnett 981 311 100 19 Total 6,276 1,127 308 48 (Strosnider) Sampson 2,347 589 192 Wayne 824 246 166 8 Pitt 2,333 680 476 23 Total 5,504 1,515 834 31 (Pridgen) Columbus 3.920 II I Onslow 3.164 547 21 i Pender 1,719 646 57 3 New Hanover - 419 108 9 .... e Total 9.222 1,312 88 4 (Covington) Halifax 2,179! 46ot 222t ii8t Northampton . 2,197! 26it l6ot 8ot Warren 862 331 212 180 Hertford 1,262 380 178 61 Total 6,500 1,432 772 439 (Hughes) Brunswick ... 1,670 865 416 126 ♦ No record and no estimate, t Estimated. Total No. people treated. Total No. treatments. 1.973 1.839 1,483 981 3.091 2,429 1,946 Mil 6,276 8,877 2,347 824 2,333 3.128 1,244 3,512 5.504 7,884 3.920 3.164 1.719 419 3,932 3,733 2,425 536 9,222 10,626 2,i79t 2,i97t 862 1,262 2,979 2,698 1,585 1,881 6,500 9,143 Five. 22 1,670 3,099 NORTH CAROLINA. 53 o g Qo" tN o" d! to ZZh vo -^ N o o 3 Ji ^ "3 ^ *^^ o "04 o" in dlvo M E-i o P^ J3 rS t: t>i u ^ " ^ COOO is. Tt E-1 o 1% 10 « w in > W w M COVO P iH in c^ -^oo fc"* i-t t-t hT hJ" .:2c2 „ rt i; u, o 3 CLtOTfLnOW o n o o c . 2 c .2tS S o C34 » bo m .SO >= n .2> h ^' -° o (-iinw" i-qg vo ■* M I o m\o fn ( I ^ CO ■ 100 to 00 " S S SJoo 10 tx ■* M wio *e tnvo m vo s o o in in\o vo o t^ 1«3 « N to !2 "^^ N-\0 m ^ q CO N^ rt ti o\ in CO c . '-3 a •a c > C4 ° 3 ™ 3 V .S.S.2 ""o ST"2'5! X S S 2 &•- ° 4j C cfl ri ^ t. -M O I •^'im of-''" « w tn CO C C C C c c S dJ OJ OJ '" "^ ^ pq to en to w m j- c c c c^ c c .§.§.§.§ S BS S S« M "I 01 448 4. Total persons treated 8,868 III. Educating the people in sanitation. By public lectures: Number of public lectures delivered 874 Estimated number of persons reached 93,499 VIRGINIA. 65 2. Through the schools : ( 1 ) Number of teachers in State 9,000 (2) Number of teachers reached by visit 1,215 (3) Number of teachers reached by letter 2,250 (4) Number of teachers reached by bulletins 9,000 (5) Number of teachers reached at institutes 2,500 3. By bulletins, leaflets and special literature : (i) Total number of bulletins and leaflets distributed 44,500 4. Through the public press : (i) Number of papers in State 268 (2) Number of papers personally visited 42 (3) Number of letters to press 125 (4) Number of articles furnished for publication 116 IV. Notes on the work of the year. 1. Regulations by the State Board of Health adopted in July, 1910, requiring sanitary privies at all the public schools went into eifect January i, 191 1. These regulations were adopted by the State Board of Education and published as a part of the State law. The work of building sanitary privies at the schools has been in progress, though it was not expected that the work would be completed within one year. 2. Alexandria county has adopted a privy regulation and is enforcing it. 3. City and town boards of health and councils have adopted privy ordinances during the year as follows : Fredericksburg, Roanoke, Ballston, Basic City, Blacksburg, Boydton, Chase City, Crewe, Emporia, Floyd, Fordwick, Gordonsville, Ken- bridge, Lexington, Pinners, Smithfield, South Hill, Stuart, Waynesboro, Williamsburg, Victoria. In Williamsburg the installation of sanitary privies was followed by a reduction in the number of cases of typhoid from an average of 30 a year to 4 for 191 1. In addition to the towns adopting and enforc- ing the privy regulations, two towns, Chase City and Law- Sb 66 VIRGINIA. renceville, are issuing bonds for sewers and several other towns are contemplating the same step. 4. In Richmond county all white schools have been pro- vided with two sanitary privies; colored schools are being equipped. In Lancaster county trustees and supervisors have agreed in writing to furnish two sanitary privies for every school; the work is in progress. In Northumberland and Westmoreland counties similar action was taken; work is in progress. In Lunenburg county the trustees have ordered privies for all schools ; some have been installed. In Mecklen- berg county school trustees requested that funds be provided by supervisors for privies at all schools; so far supervisors have not appropriated the funds. In Greenesville county trus- tees have agreed to equip all schools by fall of 1912; work is in progress. In Halifax trustees have ordered privies at all schools; work is in progress. In Campbell county resolution ordering privies at all schools has been adopted, but work has not yet begun. 5. In cities and towns, according to reports of mayors and health officers, at least 4,500 privies have been built. In schools in rural districts there have been installed 135 privies by count. In homes in rural districts, 204 privies of which we have record. 6. In districts in which active work has been done local boards have been much strengthened. The policy of the State Board of Health is to remove from local boards members who do not cooperate with the hookworm work. This has been done in one case and the reason therefor communicated to the member removed. CHAPTER III. GENERAL SUMMARY. Tabls 2. — Infection Survey — Summary. oj-xg No. counties No. children ■ surveyed. examined. Alabama 2 840 Arkansas 9 2,685 Georgia 2 568 Louisiana 10 3,638 Mississippi 17 9.561 North Carolina 21 11,466 South Carolina 3 1,188 Tennessee 13 3,271 'Virginia 10 4,05C Total 87 37,267 Percentage of infection by counties ranges from 2.5 to 90.2. 57 68 ^ tj ►J m < M g 1, o « „ 2 ^-.5 2 5 3 S " 5" 55- J5 ° o S2 o = •2 2 = a-S a S a c Ji l5" p. (U'r. V S " 2 « ° B XI 3 I?" 111! «+H CO ° C ,: 0) GENERAL SUMMARY. n VO fO lO HI w tn n ^O CO 00 OD -^ < o Oi a, .a J3 j3 Ji 3 o l-t s o iz; 3 O W 3 H > c« tn cn OJ Td r- , u s *"' a. ^ MH o o c Ih u> OJ •OJH f- g c c n1 cd O O HH GENERAL SUMMARY. 69 Is S n ™ 5 ■».«■ ►< 3 ^ 8 a (n s o s (^ in Tj- oo5 Table 6. — Sanitary Survey. State. Alabama Arkansas Georgia Louisiana Mississippi North Carolina South Carolina Tennessee Virginia No. of counties surveyed. 7 II II II 9 44 4 14 14 No. of homes inspected. 2,502 6,159 4,981 6,485 2428 13,251 2,293 2,898 2,451 Total 125 43,448 GENERAL SUMMARY. 7f CO u Estimated number of persons reached by these lectures. 5 ^n to CO ^ R "S <§^ ? 1 oT to p 1 "I u M in lo a\ lO CO ■* c 3 Ml a< ° M atd •H r^ „ ^ W CO VO O T f S 3 0) \0 CO w vO O 00 t^ O ' r» •atJ.s M CO VO -^ CO -"^ ro a •O 3 u M CO S to il o o t^ O M 8 8 S OO ^1 o o to l>» VO \D T^ VO_ 00 (N^ t^ W CTN M u I ^ (N CO cT M r to CO C • r- fl . -g "3 +J 2^ 3. § o o o O r^ Ti- 00 O lO C to ON |s ^ Tt to -^ CO lo r^ C to o ■o t^ Th lO 00 w w c K CO oJ m •^ u >n b O o *-« w "=> ^ CO u to .s en V ^ ro ':*• CO (N M lO ^ ts .a {H FQ ■o pT i~^ liO c 1^ ^ " o u J3 u |m w m liO o M MO" ■5 VO O -!l- VD O CO lO CO 1- ID *? CO CO CO !>. ID ON r^ w c -tf ts^ w M M H d^ w "^Sii ■* tN Td- M O 1 72 GENERAL SUMMARY. dJ .2 u s^ c 1 M J3 OJ ' OJ -*-' -t-i L be 5 .2 ■S.S £ -o in CO :; si : a p. a, tf (U a ; 1 OJ a 2 > u > "n 3 P< o B- 13 rally fa * Evi three ;ment. ' —gave rally fa 3 2 rally fa St with iastic sv S = * « So t = g OJ m S 3 > a; s^ ^ 1" 13 5 o o in o o o CO VO CO -^t M U-) lO — o CO « "3- •H.a § s o r^^ rO l-H 00 t^ c «*-< -is •-I Vh — ■ < 3 -2 mh 3 a 2 o ID o O to t^ o lO « Cft VO 0^ o ui Tf r^ N VO 0) fO N w hi 1 "^ ^ '-' l^ •S > " fO lO 1) ^ ^ •& u^ . 3 s Numbe ersonal visited cr« lo M ■* o M VD lO CN CO CO 00 o rO ON « ■cf ^ t^ J3 M vO a S3 u 00 o in 01 CO VO (Jv 00 o U-J K-. r^ lO o t^ V£> Ov w rO to o M rO r- CO W cs P^ -J2 .13 ui mber of illetins . leaflets ributed. ^ Tl- 00 t^ o O l^ O VO bo c W CO w 8 o ID ■* o CO s 'J c fO C7« o o_ o_ lO lO ■* fl 3 s ^" (*1 ^ i 00 O w rO OV H.D .-0 CO a _n i ri c CI 'a 2 o IH cd xh E .2 <3 6 • .55 1 cd 'a m 5 J3 a s s ^ *m -M ■& rt /< ': m Ih 3 c ;h o eg u 5 1 GBNERAI, SUMMARY. 73 3 00 9 fo ^ 00 o m CO ^ o^ tx 00 1^ uS in N 00 *! 0\ t^ 00 00 >< m O VO N VO Ov 00 " n 0\ t^ ■* ^ -i S W N w « O -^ « CO « ■* m O O 00 00, \n <\ CO M N. ■ Sj CO 0\ 5S o ■ Ov o o ^ 00 r^ tv VO ^ lO ^o i-t •* •a I n It 1 C4 X w u O O '^ "^ ^ \0 •-• CO v5 ^ 00, CO « CO >^ >o tN 00 N \o vo t^ to w in b* 00 Oj r^ CO O 00 O; "" ■* t^ to tN »o 00 S^ 5< 2. 5j ? IX o\ 00 ■* 2 o <3\ n N 0> 0\ ■* tC K \o lo & ^ o 6-1 74 OKnEral summary. Table le. — Summary of Expenditures. By State. Alabama ?3,o88. 75 Arkansas SO.oo Georgia 1,802. 30 Louisiana 5,995.00 Mississippi 7,014.00 North Carolina.. 9,300.00 South Carolina.. 291.98 Tennessee 1,546 . 70 Virginia 1,300.00 By Commission. For salaries and expenses. $10401.98 12,709.33 17,011.03 9,949-35 17,253*: 38 18,503.16 11,963.82 15,041.11 14,349-93 Foi equip- ment. $666.73 548.25 250.70 117.90 170. 10 289.80 428.50 Administrative expenses : Administrative Secretary's office. Scientific Secretary's office Treasurer's office Total. $13,490.73 13426.06 18,813-33 16,492.60 24,518.08 27,921.06 12,425.90 16,877-61 16,078.43 Total $30,388.73 $127,183.09 $2,471.98 $160,043.80 $14,384.62 3,806.28 561.17 $18,752.07 CHAPTER IV. EXHIBITS. I. Maps I to II, showing distribution of hookworm infec- tion in eleven States. Key to Maps i to io. Red Circle. — Infection heavy. Red Star. — Infection light. Blue Star. — Infection demonstrated ; degree not determined. d PP" ■ \ 1 ^ \ -rr jf < lllll^ z 4_ J i y \ ^ J^<.^><^^ \ i jL*yv \ / 0/ /^ \r'~ \ ( . /s *XOv^ \ ^"^Tm^ 1 / v.. ^A #.( _J / z z op < -J^O z ITS, : f ' ° I \ < < ^ f ^ — ' ^ oc z ^^ ■-\ \ V \ I o IS tt. UI V >,... / s ./ / > . 7 z z y h fflabama. 5 TENNESSEE GEORGIA MISS FUO R IDA M/ssissippf. 6 TENN. OE SOTO o o PBENTIS' ^yVO' '1 I |TIPPAH I Q ^»TE ^ 1maRSHall|union ^ 1TA>N*MB. (TATE ItUN^CA^ PANOLA LAFAVETTEl LEE _i, PONTOTOC Itallahatch _w • ICIA"' I* I'BOLIVARr imontg; webster'I 'K Ilowndes ""^^^ ^^^'^ LEFUORe^ OARROLL^^^^ ^^ ISUNFL.1 CT-J^ ^ T T . I n I [NOXUBEE WASHINSTON, '' Pleake IneshobaI KtHPE-R o r " 1 -^ WINSTON o o o liSSA9U7 CvAZOO - M -3i ^14, UJ u (A W bJ Z Z u H I l- 3 O y \ \ i '■" EXHIBITS. '89 9- 10. II. 12. 13- 14- 15- 16. 17- 18. 19- 20. 21. 22. 23- 24. 25- 26. 27. 28. 29. 30. 31- Forty-six Foreign Countries in Which the Infection is Widespread. I.Africa: Area (sq. mi.). Population. Algeria 184,474 4,739,556 British East Africa and Zanzibar 640 150,000 Egypt ". 400,000 9,734,405 Gold Coast Colony 40,000 474,000 Lagos and Yuraba 28,910 1,500,000 Natal 42,019 983,1 18 Sierra Leone 4,000 76,655 Tunis 51,000 1,900,000 II. Americas, The: Antigua 108 35,000 Barbados 166 195,588 Brazil 3,218,130 14,333.915 British Guiana 104,000 278,328 British Honduras 7,562 37,479 Colombia 473,202 3,593,600 Dominican Republic 18,755 417,000 Dutch Guiana or Surinam 46,060 67,128 Ecuador 1 16,000 1,205,600 French Guiana 30,500 32,908 Guatemala 48,290 1,747,000 Honduras 46,250 487,500 Jamaica 4,i93 743,ooo Martinique 381 164,000 Mexico 767,005 13.570,545 Nicaragua 49,200 380,000 Paraguay 157,000 432,000 Panama 3i,S7i 285,000 Peru 463,747 2,660,881 Porto Rico 3,606 953,243 Salvador 7.225 1,006,848 Trinidad i,7S4 253,000 Venezuela 593,943 2,323,527 7b go EXHIBITS. III. Asia: 32. Ceylon 25,333 3o78,333 33. China 4,277,170 426,047,325 34. Cochin China 23,160 2,400,000 35- India 1,766,642 294,361,056 36. Japan 161,198 46,453,249 37- Java 50,554 26,125,000 38. Korea 82,000 10,528,937 39. Malay States 26,500 676,000 40. Philippine Islands 1 14,326 7,000,000 41. Samoa 181 55.ooo 42. Straits Settlements ii>S43 5/2,000 43. Sumatra 162,310 3,472,000 44. Turkish Province of Bagdad 54.503 850,000 IV. Australia: 45. Queensland 668,497 503,266 V. Europe: 46. Italy 110,550 32,475,253 14,464,158 919,858,243 EXHIBITS. 91 2. Photographs showing: (i) Typical cases of hookworm disease and infected groups. Figures 1-6. (2) Results of treatment. Figures 7-9. (3) Dispensary groups. Figures 10-16. Fig. 2. — Showing dwarhng effect of the disease. These boys are brothers. Jones County, Miss. No. i, age 17, weight 156 pounds; light infection. No. 2, age 18, weight 74 pounds; heavy infection. 2 "o o o o u ho I ta < ^ - o s ■" o O CO I m o J3 H^ 3 S O rt c a 3 O O a o o 3:S:y i Og Si: U 3 Fig. 8. — Selma Ellis seven weeks later. August 3 his hemoglobin was 14 per cent; red corpuscles 1,050,000; last parasites expelled September 9. On September 16 his hemoglobin was 55 per cent ; red corpuscles 4.572,500; weight 79 pounds. Photograph September 16. Fig. 9. — Selma Ellis, showing the anaemic ulcer healing. Photograph September 16. Compare with photograph of July 29. J2 o o O o o m o i ^ Ui Fig. 12. — Dispensary group, lo miles from railroad, in Tishomingo County, Miss., Decem- ber 12, 191 1. Eighty-three persons treated at this dispensary on that day; some of them came 25 miles. c o U c^ & O oJ D fe 13 14 v-'m^ " fft V ■fe •a 1 o C o J2 v^ IS U o -c c o CJ u . c o Q I i6 EXHIBITS. 93 3. Typical Record Forms and Letters. No. I. {Sent to Ail Physicians in State.) Hookworm Commission. North Carolina State Board of Health. Raleigh, N. C, Dear Doctor : You will recall my previous requests for in- formation concerning your experience in treating hookworm disease. The primary object of our campaign is to get sufferers treated by local physicians. We have no way of ascertaining what progress has been made except by obtaining information directly ' from the various physicians throughout the State. Practically all the State's physicians understanding the motive of our inquiry have cheerfully filled in and returned the blanks. Will you not kindly fill in as accurately as you can and return the enclosed blank while your mind is on it? The campaign is progressing nicely. Already more than 35,000 people have been reported treated in the State by more than 600 North Carolina doctors; 1,306 doctors replied to the previous request for information ; 600 doctors have been using the State Laboratory of Hygiene to have examinations made ; 726 have distributed hookworm literature in their practice. The State and county dispensaries for the free examination aijd treatment of hookworm disease, that have already oper- ated in eight counties and have been provided for in six others, haye afforded the most gratifying stimulus yet tried for arous- ing the people. After we have remained six weeks in a county and gone, the results of treatment having been made apparent in every direction, the people in many instances who previ- ously seldom consulted physicians seek treatment from the regular practitioners. 8b 94 EXHIBITS. A wholesale drug house reports a great increase in the sale of thymol among the doctors in the counties where the dis- pensaries have been. The physicians, county commissioners, and the public have been highly pleased with the results. Please fill in the enclosed blank and return, and help the cause in every way possible. Very truly yours, Jno. A. FfiRRELL, Ass't Sec. for Hookworm Disease. J. A. F./R. No. 2. (Blank Form Enclosed with Letter "No. i.") Jno. a. Fsrrell, M. D., Ass't Sec. for Hookworm Disease, Raleigh, N. C. Dear Doctor: I am herewith giving the answers to your questions as nearly correct as practical on short notice. (Answers.) Number of cases of hookworm disease I reported having treated up to March 14, 'i i Number of cases of hookworm disease I have since treated Total number of cases of hookworm disease I have treated Number of the above cases who were negroes In order to acquaint my patrons with the disease and stimu- late interest in the work, I shall be obliged if you will send to me for distribution the supplies indicated : (Answers.) . Number of two-page leaflets on Hookworm Dis- ease Number of illustrated pamphlets on Hookworm Disease Number of illustrated bulletins, "Hookworm Edition" EXHIBITS. 95 Number of illustrated leaflets on construction of sanitary privies Number of printed prescription pads, treatment for Hookworm Disease Very truly yours, , M. D. Post Office. County, N. C. Date Note. — In filling in this blank, a report or histories of one or two of your most interesting cases will be appreciated now or later. Quite a number were published in the December Bulletin. No. 3. (Sent to Head of Family in Which Microscopic B.r- amination Has Demonstrated the Presence of Infection.) The report of , 191 . ., of the specimens sent by you to the Virginia Department of Health, at Richmond, shows that is (are) suffering with hookworm disease This is a serious matter, and if neglected these worms, by constantly feeding on the patient's blood, will cause it to be- come thin and watery and the person to become pale, weak, and, if a child, stunted in the growth of both body and mind. School children with this disease make poor progress in their studies, and may be expected to stand low in their classes. The disease can be easily cured with two or more treat- ments, a week apart, each treatment lasting only one day. When freed from the worms, the task is not complete till you adopt measures to prevent future infection. 96 EXHIBITS. This consists in providing a sanitary privy at home and see- ing that every member of the family uses it at all times. See also that children are properly protected at school, and that the trustees comply with the law requiring them to build two privies for each school-house. You thus prevent infection of the soil with hookworm eggs, which soon hatch into small worms ready to enter the body through the bare feet of all who visit such places, especially in wet weather. This produces ground-itch, which is the beginning of hook- worm disease. I wish to assure you of my deep interest in this case, and that you are at liberty to call upon me freely for advice or further aid in connection with it. Do not fail to report final result. I beg that you lend me your aid in inducing others to be examined and treated, and to adopt proper sanitary precau- tions. Yours very sincerely, No. 4. Alabama State Board of Health. To the Board of County Commissioners of Dale County. Gentlemen: This will introduce to you Dr. H. G. Perry, representative of State Board of Health of Alabama. He is in our county in the interest of the campaign for the eradica- tion of hookworm disease. The plans as outlined by him seem to be feasible and in my opinion will be of great benefit to our people. EXHIBITS. 97 The request for an appropriation by your court of one hundred and fifty dollars ($150.00) seems reasonable and will meet with my approval. This money will be used for the pur- pose of distributing literature concerning the disease and the campaign among the people, and to pay for the medicine used. The State Board of Health will furnish Dr. Perry to conduct the free dispensaries without further cost to us. In order to facilitate matters it is necessary for the money to be available at once. I therefore suggest that you sign the agreement below so that this end can be accomplished. Respectfully, C. A. B. Edwards, Probate Judge. No. 5. April 27, 1911. To the Honorable Court of County Commissioners, Dallas County, Ala. Gentlemen : We, the undersigned committee from the Dallas County Board of Health, respectfully request your body to appropriate the sum of two hundred and fifty dollars to defray the expense of advertising and medicines for the campaign for the eradication of hookworm disease in Dallas county. This is a movement of great importance from a public- health standpoint. We feel that no other expenditure of public funds will result in more good to the people. Respectfully, W. W. Harper, M. D., T. G. Howard, M. D., S. G. Gay, M. D., Committee. 98 EXHIBITS. No. 6. AivABAMA State; Board of Health. We, the undersigned members of the medical profession of Dale county, have decided that the establishment of a chain of dispensaries for the free treatment of all cases of hook- worm disease will be the most effective way to bring these patients to treatment. This is a movement which will be of the greatest public good, and as citizens and as conservators of the public health we give the dispensary plan our endorse- ment and pledge ourselves to its support. It is understood that the Court of County Commissioners will be asked to bear the local expenses of advertising and medicine, and that the State Board of Health will furnish a competent physician to conduct the dispensaries until April i at least, provided the number of patients applying for treatment will justify. (Signed) S. M. C. HowELi,. J. E. Stokes. Curtis Espey. M. O. Grace. R. G. Cary. H. D. Reynolds, Jk. A. F. TOWNSEND. W. L. HOLMON. C. R. Athoy. J. L. Reynolds. A. L. Townsend. W. D. Mixon. J. H. Patton. F. B. Cullens. E. B. Ard. No. 7. To the County Commissioners of Lowndes County: We, the undersigned members of the Board of Education of Lowndes county, express to the Georgia State Board of Health, through their Department of Field Sanitation, our ap- EXHIBITS. 99 preciation of their work toward the eradication of hookworm disease in the schools of our county. The results of the work done by the State Board of Health have shown that there is a heavy infection of hookworm dis- ease in our rural schools. We realize that this disease, by retarding the development, both mental and physical, of the school child, is each year causing a large part of our educational efforts to be wasted. We also realize that either through poverty or indifference the great majority of these sufferers are not being reached by the present methods. In view of these facts, and also in view of the excellent results accomplished by use of the plan in other Southern States, we are convinced that the only feasible plan whereby the great mass of these children will receive treatment is the plan of free dispensaries — field hospitals for the treatment of hookworm disease. Therefore we do earnestly pray the County Commissioners of Lowndes county to appropriate whatever funds may be necessary to assist the Georgia State Board of Health in the inauguration of the dispensary plan in Lowndes county. (Signed) E. P. S. Denmark, Chairman; J. G. Crawi^ord, J. C. King, W. H. McKlNNON, County Board of Education. No. 8. {Agreement Signed to Avoid Having to Wait for Regular Meeting of Commissioners' Court.) We, the undersigned members of the Commissioners' Court of Dale county, agree that at our next meeting we will appro- lOO EXHIBITS. priate the sum of one hundred and fifty dollars ($150.00) to pay the local expenses of the campaign for the eradication of hookworm disease. The money is to be placed in bank to the order of Dr. M. O. Grace, and the balance remaining after the bills are paid is to be returned to the county treasurer. (Signed) C. A. B. Edwards. A. H. Borland. T. F. Windham. A. N. Fain. No. 9. State of Georgia, County of Lowndes: We, the Commissioners of Roads and Revenues of Lowndes county, Georgia, realizing that hookworm disease is an infec- tious disease and dependent on faulty sanitation, and is a great menace to our county, and realizing that the majority of those suffering from this disease are not being reached by the plans now in vogue, and believing that the best method of reaching the great masses of those suffering is by cooperation with the Department of Field Sanitation of the Georgia State Board of Health in ridding the county of sources of infection by cure of the infected, and by teaching other proper sanitation, do hereby appropriate one hundred and fifty dollars to be used by this department of the State Board of Health in taking the steps necessary by proper means of, so far as possible, ac- complishing the eradication, preventing the generation and spread of this infectious disease. Work to be pursued for six weeks from date, or as early thereafter as practicable. (Signed) J. P. CoFFEE, Chairman. November 6. 191 1. EXHIBITS. lOI No. lo. (Sent to Leading Citizens.) Hookworm Commission. North Carolina State Board of Health. Greenville, N. C, October 17, 1911. Dear Sir: You are aware no doubt that your county has made provision to have State and county free dispensaries for the examination and treatment of hookworm disease, and that the work has been very successfully carried on in eight coun- ties, is now in progress in five counties, including your own, and has been provided for in six other counties, making a total of nineteen counties. The success in the eight counties worked was due in a large measure to the active cooperation secured from the most influ- ential citizens of the best and most thickly settled communi- ties. In less than thirty days 12,500 treatments were dispensed by four physicians in four counties. With your influence in your section of the county you can render a lasting service to your people by setting an example in visiting the dispensary and taking your family. What you do the masses will do, and Consequently on you and others of your position depends the success of the effort to bring health, happiness, and usefulness to those who, though diseased, have not the courage to take the lead in obtaining the free treat- ment they need. Leading men in all the other counties in which we have been saw and took advantage of the opportunity to help their people. We believe you will likewise seize the opportunity and work actively in every way possible to arouse the people and get them out to the dispensary. Inclosed you will find a hand-bill giving the dates and places of the dispensaries. 102 EXHIBITS. Kindly have the Sunday School superintendent and the min- ister and the school teachers to make announcements about the dispensaries and urge the people to visit them. Assuring you we shall greatly appreciate your coming out to the place nearest to you and getting as many others as possible to come, I am, Very truly yours, , Director in Charge. No. II. (Sent to All Ministers in the County.) To the Ministers of Winston County: On the first day of January there will be inaugurated in Winston county a chain of dispensaries for the free treatment of hookworm disease, and in connection practical suggestions will be offered for the improvement of local' sanitary condi- tions. Realizing that the children of this county are suffering from the effects of this devitalizing parasite and that it is draining from its poor victims the youth and vitality which it is their inalienable right to possess, we ask that the preachers of the various churches lend their influence and promise their hearty cooperation. We suggest that on the remaining Sundays between now and that time announcement be made from the pulpit relative to this work, and that you exert every influence to impress upon the individual his duty in caring for the health of his children. (Signed) ' S. B. Myers, Methodist Pastor. G. S. Jenkins, Baptist Pastor. A. J. Crawford, Presbyterian Pastor. EXHIBITS. 103 No. 12. {Typical Dodger Used to Give Publicity to the Dispensaries.) NOTICE! The State Board of Health, acting with Columbus County will open a field hospital for the treatment of HOOKWORM and other such diseases, at the following places in the county, on the dates nanied below: Chadbourn« July 10th to 16th. Whiteville, July 17th to 23rd. Fair Bluff, July 24th to 30th. Tabor, August 1st to 7th. Lake Waccamaw, August 6th to 14th. Freeman, August 14th to 21st. There will be two wards in this hospital, one for males and one for f e-- males. A physician from the State Board of Health will be in charge of the hospital and an expert from the State Laboratory of Hygiene will be. present to do the microscopic work. A lady chaperone will be in charge of the female ward and every courtesy and attention will be given all persons, rich or poor. There will be illustrated lectures and demonstrations on sanitation dai- ly. These will be in plain simple terms that any one can understand and any one can also see the workmgs of that wonderful instriiment, the mi- croscope, by simply asking the man in charge. We want every man,, woman and child to be examined while the hospital is in his or her spction. Many of the bad feelings people have, are due to hookworm and we have found that about haif of the people are infected. This is Absolutely FREE-The State and County Are Paying For It. So many people have been found infected and the results are so cer- tain and so wonderful that the County and the State feel that it is worth dollars and cents to them to restore so many of their people to health and strength. Come out on the dates named and see what is being done. Don't think it is the other fellow who needs this. It may be you. Bring a small bit of your bowel movement with you to be examined with the mi- croscope. It may be worth many dollars or may be life itself to you or your cnild. You will have only this one chance for free treatment. Respectfully, DR. C. L. PRIDGEN, State Board of Health. EXHIBITS. 105 No. 13. (Printed on Back of Envelope in Which the Drug is Dispensed; Literature on Sanitation is Given Out With This.) Directions for Taking Hookworm Treatment. 1. Eat no supper the night before taking the medicine. Take a dose of fresh salts at bedtime. 2. Next morning, take one dose of worm medicine at 6, the other at 8 o'clock. 3. Take a dose of salts at 11 o'clock and stay in the house until it acts. 4. When this has acted, you may eat anything not greasy or oily. 5. If you get weak, drink some strong plain coflfee. 6. Strain passage through cheese cloth, pouring on fresh water until everything is washed through. The worms will be left on the cloth. Put them in a bottle of clear water and bring them with you next time. 7. It may take more than one treatment to get all the worms. 8. Do not get infected again. It is your duty to keep your family well. 9. Come back next week. No. 14. {Letter Covering Report to County Authorities at the Close of the Dispensary Work.) To the Honorable Board of Commissioners of Pitt County. Gentlemen : I have the honor to transmit herewith a re- port covering the work done during our 45-day hookworm campaign in your county. I06 EXHIBITS. The attached report is self-explanatory. Total cost to Pitt county, $302.08. You will note that we examined 4,526 people (old and young), and found 2,333 infected with hookworm disease, to which number we gave a total of 4,033 treatments. I am pleased to advise you that many hundreds of your good people have been relieved of this devitalizing disease and taught how to prevent its recurrence. I wish to thank you gentlemen for your cooperation and for the many favors granted me during my labor in your county. I wish to say furthermore that such has been the courtesy and hospitality of your people that I leave Pitt county with reluc- tance. Respectfully submitted. Physician in Charge. EXHIBITS. 107 o a >< < Q g ^ ^ 1^ V c . ■^ M M 0\ l\ -^ ir)>o 00 1% CO m c^ cq M 00 "200 00 to o o 01 tx tx -^o in w CI « PI >-l -f ^J O fO rx 0\ ro CXOO 0\ Tj- ro wi CO ^O 000 O CO W tx w M M 01 " H M tx i: J2 CO ' ' ' 0.-B : : : : ■ etc • ; m cTi cd ^ (- u. ■ Ui " & > > ■ i! g. rt C o t-,.S •^ - .-a rt J3 £ = o 5 rt ^ S? tH ^ C3 S" 0"° o O ■s g f^ o ;z; « o £-1 rNOinro. Ili^ CO 0\ 10 CO ?2 CO •-< t^ CO M CO coOO 0^ rs. M m M CO IN. 00 VO CO ^i^ o 01 -^ W w CO tM w \o o g^ Onoo - - - - - - — - ^-^^ - C00\c0f0 tN.lN.O N M'Oli^"" CM CO N I-* M CH W 0^ o 3'-3 1—1 TO 4J Id I- t. - >>■>. rt i: rt o Eh 'o 'u OJ SB •9 ^00 J2 M ^ c o 1-1 I08 EXHIBITS. No. i6. (Sent to All Papers of State.) Seventy-two Hundred People Treated for Hookworm Disease in Twenty Days in Four Counties. In the counties of Sampson, Robeson, Columbus, and Hali- fax 7,260 victims of hookworm disease have been treated at the State and county dispensaries. Nearly double this num- ber have been examined. During the first five days the dis- pensaries were open only 615 cases were treated, whereas dur- ing the last five days 2,808 were treated. During the twenty days there were treated in Sampson 1,682 cases; in Robeson, 1,352; in Columbus, 3,047; and in Halifax in twelve days, 1,169 cases. The county boards of education to show their spirit of co- operation, are having sanitary privies installed at all the schooP houses being used as dispensaries. After about two weeks the dispensary work will move into new counties. Cumberland, Onslow, Wayne, and Northamp- ton counties have made the necessary provision to have the dispensaries next. The Commissioners and people generally are highly pleased with the work of the dispensaries. Dear Editor : Above I am sending a news item concerning the State and county dispensaries. Kindly use it in your next issue. Very truly yours, Jno. A. FerrELL, Ass't Sec. for Hookworm Disease. J. A. F./B. C. August 12, 1911. Initial f n 3 Case No. Z I H * : M 1 ^ i > ?8 n o 2 B Ase White 1 Colored o o Mttla Pemala 1 + 1 3 > o 1 1 + G 5" s 1 o -0 5S GlK. Thymol r n 1 z 4 Grs. I' S* ITiynwll & On. Thymol 1 Gra. Ttymol 1 Mild E i ■ Mfidiam Severe PI E > z 9b o c o u o 1 q 1 CO 5 3 O O w < w M n o o w 1 z 1 a i E X 1 ■ + ii '~ |s 1 X i 1 i e 1 s + r£ ii s 1 o z t •m 1 pu to npu n|»i 0H3 1 .5V S ■P e SI 1 apri »isn| Vtl3 »3 1U| N39 * s z 1 1 u. u ; : o 1 u a < ifi 1 1 1 i 1 1 ! t 1 Ik u o u m < E s "1. i E + 1 s E i i i o ■s s 1 •a Msnp 11 SI Oil: pus 3JN gal » ! ^ 1 i i 1 i ; i 1 1 i i j E 1 . 1 ** i 1 . i 1 1 ' 1 — ! — — i — \ — 1 — 1 a- tu : H ' j ; g; : i I ot\ : 1 1 1 ' I-; - —i — 1 ; 1 < »; 1 1 ! O -; d i 1 1 - 21 J 1 ^ S3 ol ! z' e- U si i »= = LJq « i^ 5s 5 A i 1 i \ T * 1 u -^1 -S £ : : S- i -* n i : i. i u « a r 5 i i i z 3 -t i ■■ ; s. i ' 1 1 i 1 i s. 8 £ 3 : £ o = ^ ^ 'Noiinaiiutia = = = == = ■r iSS3 HOC V = 3 am rU3i 11 — — — "1 — — — — "*5 — — — - -s £ ' s ^ - g i -o (fi 3 1 O 1 3 S i - 1 5 ^ m Sept. 8, 1347-1348. Stiles (C. W.) and Gardner (C. H.) : 19110. Soil pollution by hookworms. [Review of Pub. Health Rep., 1910, V. 25 (so), Dec. 16, 1825-1830.] < J. Am. M. Ass., Chi- cago, v. 56 (11), Mar. 18, p. 831. Stiles (C. W.) and Leonard (Geo. F.) : 1911a. Administration of Thymol in hookworm disease < Pub. Health Rep., U. S. Pub. Health and Mar.-Hosp. Serv., Wash., V. 26(49), Dec. 8, p. 1925. I40 REPORT OF THE SCIENTIFIC SECRETARY. ipiifc. Idem. [Reviewed.] < Bost. Med. & Surg. Journ., Boston, v. i6S (25), Dec. 21, p. g6i. StilBs (C. W.) and Lumsden (L. L.) ; 19110. The sanitary privy < Farmers' Bull. (463), U. S. Dep't Agric, Wash., Aug. 22, pp. 1-32, figs. 1-9. 1911&. Idem. [Review.] < J. Am. M. Ass., Chicago, v. 57 (17), Oct. 21, pp. 1371-1372- 1911C. Different kinds of privies. [Extract from 19110.] < Bull. 111. St. Bd. Health, Springfield, 111., v. 7 (9), Sept., pp. 509-328, figs. 1-9. Stiles (C. W.) and Miller (H. M.) : 19110. The ability of fly larvae to crawl through the sand < Pub. Health Rep., U. S. Pub. Health & Mar.-Hosp. Serv., Wash., V. 26 (43), Aug. 25, 1277. 1911&. Observations on the viability of eggs of hookworms (Necator americanus) and of ellworms (Ascaris lutnbricoides) in feces allowed to decompose in water < Ibidem, v. 26 (41), Oct., 13, pp. 1565-1567. 1911C. [Hookworms from Kentucky.] [Secretary's ajistract of paper read before the Helminthological Soc. of Washington, Feb. 9.] < Science, N. Y., (850), v. 33, Apr. 14, p. 592. [Also reprint, p. 2.] The Farmers' Bulletin on the Sanitary Privy, prepared by Dr. L. L. Lumsden and myself and issued by the U. S. De- partment of Agriculture, has been in great demand, and, ac- cording to information obtained from the Editor of the De- partment, it has been placed on the permanent list and will be sent free to all persons who apply for it. THE ROCKEFELLER SANITARY COMMISSION FOR THE ERADICATION OF HOOKWORM DISEASE HOOKWORM INFECTION IN FOREIGN COUNTRIES OFFICES OF THE COMMISSION WASHINGTON, D. C, U. S. A. 1911 s THE ROCKEFELLER SANITARY COMMISSION F. T. Gates Chairman William H. Welch Simon Flexner E. A. Alderman D. F. Houston P. P. Claxton WiCKLiFFE Rose Administrative Secretary 72s Southern Building Washington, D. C. J. Y. Joyner Walter H. Page H. B. Frissell J. D. Rockefeller, Jr. Starr J. Murphy C. W. Stiles Scientific Secretary 24th and E Sts. N. W. Washington, D. C L. G. Myers Treasurer INTRODUCTORY NOTE.* The Commission has undertaken to get information on hookworm disease in foreign countries. A letter was pre- pared asking for information on: i, whether or not the country has been found infected; 2, the geographic distri- bution of the infection within the country; 3, an approxi- mate estimate of the degree of infection ; 4, whether the infection is surface or mine infection ; 5, what is being done by private or public agencies to eradicate or relieve it. Through the good offices of the late Surgeon General Wy- man this letter was sent out by the Department of State with a covering letter as an official inquiry to American representatives in all foreign countries. This was followed by correspondence with physicians and public health au- thorities in these countries; these reports were supple- mented by reference to the voluminous literature of the subject on file in the library of the Surgeon General's Office, U. S. Army. The information thus gained is here sum- marized. The geographic distribution of the infection is exhibited on maps i to 6. Some features of the exhibit call for special attention: a. Extent of the infection. — Hookworm infection belts the earth in a zone about 66 degrees wide, extending from parallel 36° north to parallel 30° south; practically all countries lying between these two parallels are infected. Of the foreign countries from which the Commission has received reports, 54 are infected. In six of these coun- * This introduction is reproduced as summary in the Anriual Report for 191 1. 3 4 HOOKWORM INFECTION IN FOREIGN COUNTRIES. tries — Wales, Germany, Netherlands, Belgium, France, and Spain — the infection is wholly or chiefly confined to mines, and is found in but few definite localities; in at least 46- of these countries the infection is general and widespread. Tabular statement on page 86 shows that these 46 countries comprise an area of about 14,464,158 square miles and have a population of about 919,858,243. To this we may add 11 of our own States, with an area of 510,149 square miles and a population of 20,785,777. Of the total population of the globe — about 1,600,000,000 people in round numbers — about 940,000,000 live in countries where hookworm disease is prevalent. b. Degree of infection. — In many countries the infection is extremely prevalent. In 1904 it was estimated that 90 out of every 100 of the working population of Porto Rico were infected. My own observations in the island con- vince me that this estimate was not excessive. The reports summarized in Publication No. 6 estimate: That of the whole population of Colombia living between sea-level and 3,000 feet above, 90 per cent are infected, and this includes the great majority of the 5,000,000 of people living in this country; that of the total population of British Guiana, 50 per cent are infected, the percentage of infection among the laborers on the sugar estates being much greater; that in Dutch Guiana the infection on many plantations runs as high as 90 per cent; that over a thousand microscopic ex- aminations in French Guiana showed an infection of 35 per cent among a local population, 50 per cent among soldiers, and from 50 to 88 per cent among prisoners ; that in Egypt general estimate places the infection at 50 per cent of the laboring population ; that 50 per cent of the coolie laborers HOOKWORM INFECTION IN FOREIGN COUNTRIES. 5 on sugar and tea estates in Natal are infected, with the dis- ease spreading among natives and Europeans ; that on many plantations in Ceylon the infection runs as high as 90 per cent; that of the 300,000,000 of people of India, 60 to 80 out of every 100 harbor the parasite; that on rubber plan- tations in the Malay States the infection runs from 47 to 74 per cent; that the southern two-thirds of the Chinese Em- pire is involved with the infection in many places in the Yang-tse Valley running as high as 70 to 76 per cent among the farming| population; that of the entire population of American Samoa, about 70 per cent are infected. c. Economic significance of the disease. — ^The economic loss resulting from the disease is enormous. The physically sound coffee-picker in Porto Rico picks from 500 to 600 measures of coffee per day ; scores of anemics told me they could pick only from 100 to 250 measures per day. Ac- cording to estimates given me by the managers of a number of large haciendas in Porto Rico, the disease has reduced the average efficiency of the labor on these plantations to from 35 to 50 per cent. Dr. William M. McDonald reports that the disease is "sapping the life and energy of the popu- lation of Antigua." Dr. Parker, of Ecuador, says: "Last fall I visited one of the largest cocoa plantations near Babahoyo and found that the anemias of hookworm and chronic malaria made available not more than 33 per cent of work of the 300 laborers on that place." Dr. E. Brimont reports: "The disease has greatly retarded the development of French Guiana." The report from British Guiana says : "The economic loss due to hookworm disease on the sugar estates is heavy. On one estate, where the laborers were treated on a large scale, the manager reported that 'the 6 HOOKWORM INFECTION IN FOREIGN COUNTRIES. working power of the gangs had increased lOO per cent.' " The report from Colombia, after stating that the infection is among the miners and in abundant profusion throughout the agricultural sections, where the laborers on the coffee, sugar, rubber, tobacco, banana, and other plantations are seemingly all affected, says that "one of the greatest prob- lems with which the people of Colombia are confronted at the present time is that of the evils attendant upon the presence of hookworm infection." Dr. T. F. McDonald, of Queensland, reporting conditions in the Johnstone River district, says that infection is present in every square mile of it, and that "it is sucking the heart's blood of the whole community." The Right Honorable the Earl of Crew, Sec- retary of State for the Colonies, in his dispatch on this subject to the Governor of Ceylon, says: "Having con- sidered the reports from the several colonies, with the ob- servations of the committee upon them, I recognize that the loss of labor caused by the prevalence of ancylostomiasis is very serious, and affects prejudicially not only the em- ployers of labor, but the community at large. Not only is there serious loss of life, direct and indirect, but also through the invaliding of laborers the charges for hospital and pauper expenditures are largely increased." In 1908 Dr. Braddon examined 2,000 sick Tamils on the rubber estates in Negri Sembilan, Malay States, and says "there was no single one of these coolies who was not affected by ancylostomiasis" ; "that 60 per cent of all coolies at work were in an advanced state of ankylostomiasis." Dr. Gra- ham, reporting for Lower Perack, Malay States, says that more than 50 per cent of the entire population is infected and that the disease is of "great economic importance to the rubber industry." HOOKWORM INFECTION IN FOREIGN COUNTRIES. 7 In our own country Dr. Herbert Gunn, special inspector for the California State Board of Health, in his report on hookworm infection in the mines of that State, says : "There is no question that the general efficiency of the men is noticeably impaired. At one mine, employing about 300 laborers, it was stated that a reserve of about 25 men had to be available to replace those who, on account of sickness, did not appear for work. Quite a few of the men have to, lay off every now and again to recuperate. Several who were unable to work stated that when they arrived in Jack- son they were perfectly strong and well. A large number of these men were encountered on the streets, some of them presenting marked degrees of anemia. The greatest loss to mine operators is occasioned by the large number of those moderately affected. * * * a. loss of 20 per cent in efficiency of those infected would be a conservative esti- mate. That would mean in Mine No. 2, for instance, where over 300 men are employed at an average of about $2.50 per day, and estimating the number of those infected as low as 50 per cent, a loss of over $20,000 a year." This estimate is for one mine. Dr. Gunn reports "that infection undoubtedly is present in practically all of the gold mines of California. Infection is present, also, among agricultural laborers of that State." But the infection in California is light as compafed with nine or ten of our South Atlantic and Gulf States) with their 20,000,000 of people. If an infection of 50 per cent in one gold mine employing 300 men causes a loss conservatively estimated at over $20,000 a year, what must be the economic significance of this disease for India, with its 300,000,000 of people and from 60 to 80 per cent of them infected ? 8 HOOKWORM INFECTION IN FOREIGN COUNTRIES. d. Retarding effect on education and civilisation. — A pho- tograph on file in this office shows a group of children, no one of whom until this year had ever been in a school; no member of their parents' family, of the grandparents' fam- ily, or their great-grandparents' family on either side had ever gone to school. We have in this family a record of at least four generations of illiteracy due to the disabling effects of hookworm disease. In the community in which this family lives are many other families showing a similar history. I have visited many communities in which a large proporton of the children have been kept out of school by disability due to this cause. I have visited schools and have on file records of many others in which all or a large pro- portion of the children attending are infected. Records of the definite survey show in extreme cases an average infec- tion among rural children of school age for whole counties running as high as 70 to 90 per cent. The statement by Dr. E. Brimont, that "the disease has greatly retarded the development of French Guiana," is applicable even in greater degree to many other countries. Acute disease may strengthen a race by killing off the weak ; but hookworm disease is chronic. It works subtly through long periods of time, and its cumulative results — physical, intellectual, economic, and moral — are handed down as an increasing handicap from generation to generation. The letter on page 102, Second Annual Report of the Rockefeller Sanitary Commission, showing the effects of the disease on one community, is a statement in concrete miniature of what it means in the large. This letter portrays a situation which for our States is extreme ; but many countries, like Egypt, India, and China, have suffered a heavy infection for cen- HOOKWORM INFECTION IN FOREIGN COUNTRIES. 9 turies, and its results have been handed down from genera- tion to generation for ages as a cumulative handicap to the development of these people in all things that make for civilization. e. Spread of the infection by immigration. — It is esti- mated that from 60 to 80 per cent of the total population of India are infected. Every country importing coolie la- borers from India is bringing on to its own soil a heavy stream of infection. In Assam Dr. Bently examined 600 Indian coolies just arrived, and found only one of them free from infection. When the attention of the govern- ment at Durban was called to the heavy infection among the coolie laborers on the sugar estates of Natal in 1908, the authorities examined the next shipload of coolies from India and found 93 per cent of them infected. The Indian coolie is the chief source of labor supply for British Guiana ; examination of all coolies arriving for the year 1909 showed an average infection of 74.44 per cent; this importation of coolie labor is regarded as the source of the present ex- tremely disastrous infection in that country. About 16,000 Indian coolies have been imported into Jamaica, and it is estimated that 50 per cent of them are now infected. By the importation of coolie labor the infection has been car- ried and is being carried from India also into Dutch Guiana, Ceylon, the Federated Malay States, the Straits Settlements, and Java. The health authorities at San Francisco exam- ined a shipload of Indian coolies just arrived at that port last year, found an infection of about 90 per cent, and estab- lished quarantine against further immigration of this type. Every group of Indian coolies now in California is a center from which the infection is spreading in that State. From lO HOOKWORM INFECTION IN FOREIGN COUNTRIES. the outbreak of the disease in the St. Gothard tunnel the infection was carried into the mines of Austria, Belgium, and Germany. In these countries large sums have already been spent in a systematic effort for its eradication. These, among a multitude of similar facts, suffice to show that hookworm disease, in the light of our present knowl- edge, has ceased to be a local matter; it is an international problem of serious proportions. WicKLiEEE Rose, Administrative Secretary. HOOKWORM INFECTION IN FOREIGN COUNTRIES. I. AFRICA. ALGERIA. I. Distribution of infection. — Albert W. Robert, Ameri- can Consul at Algiers, reports infection in the oasis of Hodna, Province of Algiers, and in the vicinity of the town of Mostaganem, Province of Oran. Sergent and De Mouzon report a heavy infection in the Oasis Mdoukal, Province of Hodna, and add this suggestive information : "It is a standing custom of the inhabitants of Mdoukal to emigrate each year to the number of about 150 to seek work in the coast towns. They reside in these towns for several years, then after they have accumulated some money return to Mdoukal. All those in whose stools we discovered Ancylostoma eggs at Mdoukal had lived for several months at Algiers. * * * These poor people among whom we demonstrated a heavy infection traverse the whole of Algeria in their journeyings." Thomas H. Kearney, in describing the workers in the date gardens of Nefta and Tozer in the Jerid, Tunis, speaks of the "lank forms and sullen anemic visages of the resi- dents of the Jerid." These date gardens in the oases are jungles of tropical growth abundantly watered by irrigation; the climate, the shade, the moisture, make an ideal incubator for the eggs and larvae of the parasite. In these groves the natives work with bare feet and unprotected legs and hands. All these 12 HOOKWORM INFECTION IN FOREIGN COUNTRIES. facts taken together make it highly probable that the in- fection exists in practically all the oases throughout Al- geria and Tunis. 2. Degree of infection. — Sergent and De Mouzon ex- amined 7 anemics at Mdoukal and found 7 infected ; they examined 8 persons taken at random showing no signs of anaemia and found 4 of them infected. The Consul at Algiers reports cases as "very common in the Hodna and erratic only near Mostaganem." Dr. Ferrier examined at Mostaganem about 100 persons and found 8 infected (Bull. Med. de I'Algerier, Alger., 1905, XVI, 482-488). 3. Relief measures. — Nothing is being done to relieve the present sufferers or to eradicate the disease. BRITISH EAST AFRICA AND ZANZIBAR. I. Prevalence of the disease. — Alexander W. Weddell, American Consul, reports that in British East Africa the disease has been recorded as present in Mombasa, Malindi, and .Voi ; that it is well known to the coast tribes under the name of "safura." For Zanzibar he reports that for the six months ending June 30, 191 1, there were reported 122 deaths from hook- worm disease on the Island of Zanzibar. These deaths were distributed as follows : Mkokotoni District (agricultural) 76 Mwera District (agricultural) 44 Chwaka District (many fishermen) 2 Total 122 HOOKWORM INFECTION IN FOREIGN COUNTRIES. I3 2. Preventive measures. — According to the above report, routine treatment is given in the Government Hospital, Poor House, and prisons to natives showing pallor. For British East Africa the Government authorities say : "It is hoped that the schemes for sanitary improvement which are under consideration will result in the incidence of the disease being lessened." EGYPT. 1. Distribution of infection. — The infection is heaviest in the Delta, but it is present in every province; it is con- fined chiefly to agricultural laborers ; recruiting officers find it less severe among black troops. Dr. Looss reports finding only the Ancylostoma duodenale present. 2. Degree of infection. — No exact investigation to deter- mine the degree of infection has been made ; it is reported very heavy. (Department of Public Health of the Egyptian Government.) Of all autopsies at Kasr-el-Aing Hospital, Cairo, 90 per cent of cases were infected. (Dr. A. G. Salter.) General estimate places the infection at about 50 per cent of the laboring population. 3. History. — For centuries Egypt has been a center from which the infection has spread to other countries. A papyrus written about 3460 years ago gives an accurate description of the A. A. A. disease, which some authors interpret as hookworm disease. In 1833 Mr. Hamant re- ported its presence among the peasants and soldiers. In 1883 Sandwith is struck with the anaemia among the sol- diers in the Cairo hospital. Treatment began in 1887. In 14 HOOKWORM INFECTION IN FOREIGN COUNTRIES. 1894 Dr. Looss came to Alexandria and Cairo and later he worked out the life-history of the parasite. 4. Conditions favoring the spread of infection in Egypt. — Latrines unknown; laborers work all day with bare feet, bare legs and hands exposed to damp infected earth (F. M. Sandwith). Temperature makes this possible the year round. 5. What is being done to alleviate or eradicate the disease. — Treatment is given at the Government hospitals and dispensaries. Public latrines in the mosques are made as sanitary as possible ; no general movement for its eradi- cation. GOLD COAST COLONY. -I. Prevalence of infection. — The British Secretary for the Colony reports : "Hookworm disease is prevalent in the Colony. The parasite Necator americanus appears to be existent rather than Ancylostoma duodenale. Its presence has been demonstrated in Fanti country, Akyem and Volta River District. Dr. Fisch, Basel Mission, estimates the de- gree of infection in Aburi as over 50 per cent in natives there, but there has been no official estimate. Workers in mines would appear to be little affected, the districts above mentioned being mostly agricultural; but cases have been recorded in Europeans working in mines." 2. Preventive measures. — The report continues on this point: "The steps taken are those of general sanitary prin- ciples in connection with washing places and latrines, and the question of applicability of the MacGregor principle is under consideration." HOOKWORM INFECTION IN FOREIGN COUNTRIES. 1 5 LAGOS. I. Prevalence of infection. — Dr. Henry Strachan, Chief Medical Officer, reports the discovery of uncinariasis in Lagos* : "There is marked mortality among the natives from 'dropsy' and 'anaemia'. On seeing some of the cases so diagnosed, I was struck with the resemblance to the ancylostomiasis of the West Indies, and on examination the presence of the causative parasite was at once demon- strated." Treatment with thymol proved efficacious. NATAL. 1. Discovery. — The presence of hookworm infection in Natal was first demonstrated by the discovery of hookworm eggs by Dr. Boufa of Tougatt in 1906. This discovery was repeated two months later by Dr. John J. Elliott, Indian Medical Officer at Verulam. 2. Prevalence of the infection. — The population of Natal consists of natives 700,000, Europeans 80,000, Indians 200,- 000. Investigations conducted by Dr. Elliott show : (i) Of the coolie laborers on the sugar and tea estates about 50 per cent are infected. (2) Of the Indian population at the port of Durban about 80 per cent are infected. (3) From the 200,000 Indians the infection is spread- ing to the native kafirs. The infection is spreading from the coast inland. (4) The infection is spreading among the Europeans. 3. Conditions in Natal favoring the spread of the in- *J. Trop. M., Lond., 1898-9, v. I, p. 208. l6 HOOKWORM INFECTION IN FOREIGN COUNTRIES. fection. — Heat tropical in intensity; rainfall regular and plentiful on the plantations. The Indian coolies are herded in barracks ; they go bare- footed and wear scant clothing; their idea of sanitation and personal cleanliness is of the most elementary; it is a pre- vailing custom to keep wholesale scavengers attached to the barracks in the shape of swine, hens and muscovy ducks ; the children, barefooted and bare-bodied, play in the filth around the barracks, become heavily infected and cannot be made to conform to sanitary regulations. The 700,000 native kafirs are herded in great "locations" or "settlements". They are being brought into closer and closer relations to the Indians and the infection is spreading among them. Indian traders and free farmers circulate freely over the whqje colony. "The open life led by Europeans in Natal, the dwelling in tents in the hot season, and in beach residences with im- perfect closet arrangements, the al fresco habits of Indian servants attached to households, the custom of allowing white children to run barefooted or sandaled, all contribute toward the spread of the disease among Europeans." 4. Origin of the infection. — Dr. Elliott of Verulam and Dr. Turner of Johannesburg attribute the spread of hook- worm infection in Natal and Southeast Africa to the im- portation of coolie laborers from India. The 200,000 In- dians in Natal represent the results of an unchecked immi- gration mainly from Calcutta and Madras for 40 years. A recent report states that the great majority of the whole native population of India is infected with hookworm dis- ease. The infection was first discovered in 1906 among the Indian coolies ; further examinations showed heavy in- HOOKWORM INFECTION IN FOREIGN COUNTRIES. 1 7 fections all along the coast from Cape Colony to Zulu. It was discovered later that immigrants fresh from India showed heavy infection. In 1908 the attention of the Gov- ernment of Natal was called to the fact that recent ship- loads had shown a large percentage ; the Health Department examined the next immigrant ship and found 93 per cent infected. Dr. Turner in a report giving the results of post-mortem examinations of natives newly arrived in Johannesburg shows no infection found among the natives living in Cape Colony, Orange River Colony, Transvaal, Bechuanaland, Basutoland, Matabele and Mashona ; but of the natives from seaport districts the infection is heavy, the percentage of infection of all those examined being for the Mozambique Tribe 64; Quillemane 64; Beira 100; Nyassa 54; Myambaan 35 ; Shangaan 35 ; British Central Africa 25 ; Angoni 18. These facts are interpreted as indicating that the infection is from India; that it is spreading in Africa along the sea- board and thence inland to the native races by contamination by Indian traders and coolie laborers. 5. What is being done to control the infection. — When in 1908 the Government of Natal was advised by the Health Department that of the immigrant ship inspected 93 per cent were found infected^ a cabinet meeting was called and it was decided to send the shipload back to India. This was abandoned for the reason that to be consistent every in- fected sugar and tea estate in the colony would have to be cleared of its Indians and this was too big an undertaking. The ship was quarantined for months; succeeding ships have been held in quarantine by the Government. The Colonial Health Department has thus made itself very un- l8 HOOKWORM INFECTION IN FOREIGN COUNTRIES. popular with the planters of Natal. On the estates the coolies are being treated. Latrines are supplied at many of the barracks but the regulations for their use are not lived up to, the children especially resist regulations and the workers persist in polluting the soil in the cane fields. Dur- ing the year 191 1 all infected immigrants have been given one course of treatment before being assigned to estates. (Information by A. B. Stewart, American Consul at Dur- ban.) SIERRA LEONE. 1. Distribution of infection. — The Colonial Secretary re- ports that, up to the present, infection has been found only at Freetown ; here it is common among the poorer classes. 2. Degree of infection. — Data insufficient for an approxi- mate estimate of degree; infection is reported as "common among poorer classes" at Freetown ; as not seeming "seri- ously to trouble the inhabitants." 3. Relief measures. — Nothing is being done to eradicate the disease, TUNIS. I. Distribution of infection. — Doctors E. Gobert and G. Gatouillard in describing the inhabitants of South Tunis say: "The traveler who goes for the first time into the oases of Tozer, of El Oudiane, or of Nefta is struck at once by the physical decadence of the population and the great num- ber of extreme anemics that he meets. These anemics are very often inveterate dirt-eaters. It was the discovery of this that led us to make a systematic investigation for Ancylostoma." This investigation demonstrated the pres- HOOKWORM INFECTION IN FOREIGN COUNTRIES. IQ ence of infection at these places. Dr. P. Sonsino demon- strated the presence of hookworm at Gabes and at Gafsa. This later report confirms the judgment expressed when describing the date gardens of the Jerid in connection with conditions in Algeria. (See Distribution of Infection in Algeria.) 2. Degree of infection. — There has not been sufficient investigation to justify an estimate of the degree "of infec- tion. Gobert and Gatouillard examined 107 persons and found 22 of them infected ; only one slide was examined in each case ; clearly the percentage of infection was much heavier. They found also a heavy infection of other in- testinal parasites. The dirt-eating habit among these people is extreme ; 60 per cent of those found infected were con- firmed dirt-eaters. The dirt-eater keeps a large store of his choice dirt at his house and carries a small bit with him wherever he goes. 3. Relief measures. — Nothing is being done to alleviate or eradicate the disease. II. THE AMERICAS. ANTIGUA. 1. Distribution of infection. — In 1897 Dr. Galgey of St. Lucia, reported the disease as endemic and prevalent all over the West Indies. Dr. H. A. A. Nichols (1900a), of Dominica, quotes the statement with approval;* he reports further that infection is not uncommon in Dominica, but on account of sparse population and an abundance of pure run- ning water the .chances of infection are much less than in Antigua ; that infection is extremely prevalent in" Antigua ; that conditions indicate that it has been here for a long time and is the same as the "negro cachexy" described by early physicians. 2. Degree of infection. — In the light of present knowl- edge the degree of infection cannot be stated in terms of percentages. Dr. Wm. M. McDonald (1900a), Acting Medi- cal Superintendent at Halberton Institute, Antigua, states that within 13 months he had in the hospital 148 cases; that these were extreme; that all had been unable to work for from 6 to 12 months ; that 34 of them died ; that the disease is sapping the life and energy of the laboring population of Antigua, f 3. Conditions favoring spread of infection. — Dr. Mc- Donald states that the population is dense ; that the water supply is the worst, being dirty pond water; that all cane fields are open latrines; that during rains, the wash from " J. Trop. M., Lond., 1900, v. 2, p. 247. t J. Trop. M., Lond., 1900, v. 2, p. 297. 20 HOOKWORM INFECTION IN FOREIGN COUNTRIES. 21 these cane fields finds its way into the ponds that supply drinking water to the natives. To this may be added the tropical climate and the habit of going barefooted the year round. 4. Relief measures. — According to Dr. McDonald noth- ing is being done to relieve the situation. Even the sick are not properly cared for. He has reported the situation to the Government. ARGENTINA. I. Disease not prevalent. — The American Consul at Buenos Aires, R. M. Bartleman, submits a communication from the National Department of Hygiene, stating that in the Federal Capital statistics have been kept of about 31 cases of hookworm disease ; that these are imported cases ; that the disease does not exist in Argentina. BARBADOS, W. I. The American Consul at Barbados reports ; 1. Distribution of infection. — ''The country is infected. The districts chiefly infected are the Parishes of St. An- drew, St. Joseph, and the lower part of St. John, but oc- casionally cases occur in the other parishes. * * * In- fection is agricultural." 2. Degree of infection. — "In the absence of reliable sta- tistics an approximate estimate of the degree of infection can not be given, but the number of cases is not great, or at any rate, the cases that present severe symptoms." 3. Relief measures. — "Ordinary sanitary by-laws are enforced as far as possible but no special measures are di- rected against the disease." 22 HOOKWORM INFECTION IN FOREIGN COUNTRIES. BRAZIL. I. Distribution of infection. a. Para: Consul George H. Pickerell, at Para, reports : "Hookworm infection undoubtedly exists in the whole Amazon River District. This opinion is based upon our local hospital practice, the hospitals accepting persons com- ing from interior points or other states." He says that the infection is agricultural ; that there are no mines. b. Bahia: Consul S. P. Warner, Bahia, reports that "hook- worm infection is general throughout the state of Bahia, especially among the lower classes" ; that the infection is agricultural. c. Sao Paulo: Paulo R. Pestano, Director of Commerce and Industry, at Sao Paulo, reports that hookworm infec- tion in the state of Sao Paulo is most prevalent in the regions traversed by the Sorocabana, the Paulista, and the Central of Brazil railroads ; that the infection is agricultural. Consul Jay White, at Santos, submits a map showing the infection to be distributed over practically the whole state. d. Brazil as a whole: Dr. Sampio Vianna, for the Director General of Public Health at Rio de Janeiro, says that hook- worm infection is observed in almost all the States of Bra- zil; that the disease is most prevalent in the northern and central regions. Mr. Lay, Consul General at Rio de Janeiro, writes: "This disease exists throughout a great section of the nation of Brazil." 2. Degree of infection. — The degree of infection cannot be definitely stated on i the basis of available data. The in- fection is reported as heavier in the northern and central regions; in a state as far south as Sao Paulo, 151 of the HOOKWORM INFECTION IN FOREIGN COUNTRIES. 23 171 counties of the state reported deaths from hookworm disease for 1910. For 1909 there were 478 deaths from hookworm disease reported for the state of Sao Paulo ; these by municipalities were : Taubate, 41 ; Sao Jose dos Campos, 36; Santos, 32; Jaher, 26; Beheduro, 23; Soccorro, 15; Botucatu, 10; Dais Corregos, 9; Barretos, 8; Agudos, 7; Bariry, 8. 3. Relief measures. — The Brazilian Government, acting on the vote of the Fourth Latin-American Medical Con- gress, held in Rio de Janeiro in 1909, has recommended through the General Department of Public Health the fol- lowing preventive measures : 0. Protection, by the use of boots, of mine workers and all who handle brick, pottery, earth roofing material, etc., and all persons engaged in agriculture. b. Disinfection of the excrement of persons infected with hookworm disease. c. Disinfection of mines, of factories, and of the yards of farmers. d. Isolation and treatment of infected persons, who should not be allowed to return to work until the stool is free from eggs of the parasite. BRITISH GUIANA. 1. Distribution of the infection. — The whole of British Guiana is infected with hookworm disease. Infection is heaviest on the sugar estates which occupy practically the whole coastal area. It is agricultural mainly. 2. Degree of infection. — It is estimted that about 50 per cent of the population of the Colony are infected. (Robert 24 HOOKWORM INFECTION IN FOREIGN COUNTRIES. A. Crance, American Vice Consul.) The percentage of in- fection among the cooly laborers on the sugar estates is much greater. Of the Indian immigrants brought into the country in 1909, 74-44 per cent were infected. (W. F. Law, M. D., Medical Inspector.) On one ship this year (1911) the infection was 78.5 per cent. This immigration from India is the chief source of labor supply for the sugar estates. 3. Origin of infection. — It is not known whether there was any infection in the Colony before the importation of cooly labor from India ; there is no evidence of its existence there previous to this time. The bulk of the labor supply for British Guiana consists of East Indians brought to the country under indenture. This immigration is bringing into the country a constant stream of new infection. 4. Economic significance of the disease. — Dr. Law, the Government Medical Inspector reports the economic loss due to hookworm disease on the sugar estates as heavy. On one estate where the laborers were treated on a large scale the manager reported that the working power of the gangs had increased 100 per cent. 5. What is being done to alleviate or eradicate the dis- ease. — In 1888 Dr. Griem called attention to the existence of hookworm infection in British Guiana; since that time the subject has received increasing attention. From 1904 to 1908 about 39,000 cases were treated in the estate hospitals. In 1908 the Governor advised the estate owners that in future allotment of immigrants might be made conditional on the provision of suitable latrine accommodations. In his report for 1910 the Government Medical Inspector says: HOOKWORM INFECTION IN FOREIGN COUNTRIES. 2$ "This mild compulsion has had such a good effect that now practically every estate has a good and effective latrine sys- tem, and planters who were formerly my strongest op- ponents are now firm believers in the usefulness of propei sanitary accommodations for their laborers." In this same report the Medical Inspector calls attention to the new infection introduced by the immigrants ; he says : "Last season was the worst we have as yet experienced in this direction, 74.44 per cent of the immigrants having been found infected on arrival. * * * Measures should cer- tainly be taken either in India or on board ship to treat these cases, otherwise we shall be compelled in self-defense to isolate evei"y one on arrival." BRITISH HONDURAS. 1. Distribution of infection. — J. H. Hugh Harrison, Colonial Surgeon, reports* that hookworm infection plays an important part in the death rate of the colony; that in- fection is general through the colony; that it seems to be especially heavy along the banks of the Belize river and ex- tending up to the frontier and also in the northern districts ; that cases came to the hospital from Placencia, in the south, from Bacalar Chico in the north, and from so many places distributed over the Colony as to settle the question that infection is most general. 2. Degree of infection. — Dr. Harrison reports : "Post- mortems have demonstrated the fact that these parasites were present in about 70 per cent of the cases." Beyond such hospital work no systematic survey has been made. *J. Trop. M., Lond., 1909, v. 12 (18), p. 275. 26 HOOKWORM INFECTION IN FOREIGN COUNTRIES. 3. Conditions favoring spread of infection. — The people of the Colony, for drinking water and for bathing purposes, avoid running streams and prefer standing pools, which they say are collections of pure rain water. These pools are polluted. To this are added a tropical climate, primitive sanitary habits, and the custom of going barefooted the year round. 4. Relief measures. — The cases that come to the atten- tion of private practitioners are being treated. No sys- tematic relief measures have been adopted ; the people are ignorant even of the presence of the disease. COLOMBIA. 1. Distribution of infection. — Charles H. Small, vice and deputy Consul General at Bogota, reports that the great majority of the inhabitants of Colombia, the population of which is estimated at 5,000,000, live in the lowlands, where the temperature is between 60° and 100° Fahrenheit and the altitude varies from sea-level to perhaps 3,000 feet above; that it is reliably stated that nine out of every ten persons living in these districts are afflicted with hookworm disease; that the infection is among the miners, and is in abundant profusion throughout the agricultural sections, where the laborers on the coffee, sugar, rubber, tobacco, banana, and other plantations are seemingly all affected ; that the parasite is also found in the higher regions, such as the plateau of Bogota, 8,000 feet above sea-level; but, on account of the cool climate, the infection in these higher regions is light. 2. Degree of infection. — On this point Mr. Small says: "In general, it may be stated that, with the exception of that HOOKWORM INFECTION IN FOREIGN COUNTRIES. 27 portion of Colombia situated at a greater altitude than 3,000 feet, the entire country is infected with hookworm, and that within the infected areas about 90 per cent of the inhabi- tants are victims of the pest.'' 3. Conditions favoring the spread of the disease. — This report continues : "The swampy, damp regions, filled with decomposing vegetable matter, and which predominate throughout the lowlands of Colombia, ofifer a fertile field for the increasing growth of the hookworm, especially in view of the fact that the native inhabitants of these dis- tricts are but little inclined to the practice of hygienic or sanitary measures of any kind." 4. Relief measures. — On this point Mr. Small says that, "according to the most prominent Colombian scientists, one of the greatest problems with which the people of Colombia are confronted at the present time is that of the evils at- tendant upon the presence of hookworm infection" ; that "thus far the Government officials of this RepubHc have taken no official cognizance of the hookworm infection as a menace to the health of the people and its retarding effects upon national progress" ; that the investigations thus far made have been made by public-spirited physicians and scientists, and that they have all arrived at practically simi- lar conclusions. "It is hoped," he says, "that in the future either the Government or some philanthropic organization will provide funds to be employed in a scientific and sys- tematic attempt to eradicate this pest." 28 HOOKWORM INFECTION IN FOREIGN COUNTRIES. DOMINICAN REPUBLIC. 1. Distribution of infection. — F. M. Endicott, Consul General at Santo Domingo, reports that the greatest num- ber of cases exist in the heart of the Cibao Province, where the population, entirely rural, is most widely infected ; that in the province of Sabana de la JNIar the disease has made rapid progress; that, with the exception of the southern portion of the island, the entire country is infected; that the infection is agricultural; that in the Cibao district the larvse find conditions most favorable to their development; and that the natives earning their living solely from the cultivation of cocoa walk barefooted through the planta- tions and get the germs of the disease. 2. Degree of infection. — The degree of infection cannot be stated at present in percentages. Mr. Endicott reports on this subject: "It appears certain that it is spreading, and, far from decreasing, continues steadily on the increase. Certain regions where the disease had never been reported are at present infected. This could hardly be otherwise, as no hygienic precautions have been taken, and the natives of the country are completely ignorant of the most elemen- tary laws of hygiene. The districts which have suffered most from this disease 'may be named in the following order : The Cibao Province, Sabana de la Mar, and the Seybo district." 3. Preventive measures. — There are none. In 1906 Dr. Defillo wrote in the Revue Dominicaine : "In view of the magnitude of the peril I have not been inactive. I duly informed the Minister of War of the serious fears I enter- tained of the spread of this disease. * * * If those HOOKWORM INFECTION IN FOREIGN COUNTRIES. 29 whose duty it is to watch over the public health shall not take all possible measures to check the invasion of hook- worrr) disease, in a short while it will spread and produce among our countrymen as great ravages as it has already done among other peoples." Mr. Endicott says that no pre- ,ventive measures have been adopted, and that the disease has spread. ECUADOR. I. Prevalence of hookworm infection. — Dr. Herman B. Parker, Passed- Assistant Surgeon, U. S. Public Health and Marine Hospital Service, reports under date of May 17, 1911 : "On my arrival in Ecuador I was impressed with the severe anemias that prevail here, and, shortly after the ar- rival of my laboratory outfit, verified the cause of these anemias as hookworm infection. I have not conducted any investigation as to the actual presence of the parasite out- side of Guayaquil, but in the places visited I have met with the same severe clinical type of anemia that characterizes this infection. "I noticed this anemia more particularly in the coast towns of the Province of Manabi, where the towns are built on or close to the sandy shores of the Pacific and have a primitive sewage disposal and a common unprotected water supply. Fishing, agriculture, and a small amount of commerce are the principal pursuits of those places." There are few mines in Ecuador, and these are remark- ably free from all infection, due to modern disposal of sewage and safe supply of drinking water. "Regarding the altitudes," continues Dr. Parker, "a most interesting condition is met with ; here the natives, more 30 HOOKWORM INFECTION IN FOREIGN COUNTRIES. particularly the Indians, are of a distinct physical type, being free from the anemias that characterize the lowlands, having clear complexions with rosy cheeks, showing the apparent absence of these infections." 2. Economic importance of the disease. — Dr. Parker reports : "Last fall I visited one of the largest cocoa planta- tions near Babahoyo and found that the anemias of hook- worm and chronic malaria reduced the efficiency of the 300 laborers on that place to not more than 33 per cent." 3. What is being done to eradicate the disease. — Dr. Parker writes: "Nothing, by either public or private agen- cies, is being done to alleviate or eradicate the disease." FRENCH GUIANA. 1. Distribution of infection. — Systematic examinations of prisoners and soldiers made by Dr. E. Brimont indicate that infection is general throughout French Guiana. 2. Degree of infection. — ^The degree of infection is indi- cated by the following results of Dr. Brimont's examina- tion: a. Prisoners at Saint-Laurent : examined, 406 ; infected, 71.92 per cent. b. Prisoners at Saint Jean du Maroni : examined, 233 ; infected, 73.39 per cent. c. Prisoners at lies du Salut: examined, 157; infected, 50.95 per cent. d. Prisoners at Cayenne : examined, 63 ; infected, 88.88 per cent. e. Local population at Saint-Laurent: infected, 35 per cent. /. Soldiers : total number examined not given ; infected, 50 per cent. HOOKWORM INFECTION IN FOREIGN COUNTRIES. 3 1 The report further states that the disease has greatly re- tarded the development of French Guiana.* 3. Relief measures.— No report on this subject. GUATEMALA. 1. Distribution of infection. — The fact that hookworm infection has been demonstrated in all the States of south- ern Mexico, in British Honduras, Honduras, and Salvador, would indicate that the whole of Guatemala is involved. The presence of hookworm infection in Guatemala was first announced by Dr. H. Prowe in 1889. His later investiga- tions demonstrate a prevalent infection. He reports (1899a) that the infection seems to be most prevalent along the coast among the neighboring hills, and in the high valleys of the Cordillera ; that in different parts of Guatemala he has met with many hundreds of cases of the disease. 2. Degree of infection. — The following records of in- vestigations by Dr. Prowe serve as a rough index to the degree of infection : a. Hospital at Ritalhuleu, Guatemala, September, 1893, to March, 1894: of 522 patients received, 246 had hookworm disease. b. Of 83 autopsies, hookworms were found in 46 cases ; in 25 of these cases it was the sole cause of death. c. On a- coffee plantation, during 28 months 1,286 sick people were under care ; of these, 528 had hook- worm disease ; 43 of these cases died of the dis- ease. 3. Relief measures. — No report on the subject. * Arch, de parasitol., Par., 1906, v. 10 (3), p. 459. *Arch. f. path. Anat. [etc.], Berl., 1899, v. 7 (3), pp. 458-474. 32 HOOKWORJI INFECTION IN FOREIGN COUNTRIES. HONDURAS. 1. Distribution of infection. — Claude I. Dawson, Ameri- can Consul at Puerto Cortes, report's that hookworm infec- tion prevails to a considerable extent throughout Hon- duras; that the infection is general, but is most prevalent in the interior and coast agricultural districts ; that it is not frequently seen along the extreme north coast. Infection is rural and agricultural. 2. Degree of infection. — No systematic investigation has been made in Honduras. Mr. Dawson quotes an American physician on the northern coast as follows: "In this imme- diate section of the country it is extremely rare. In looking over my case records I find I have had only two cases in the last ten years. In the interior towns and rural districts there is a complete absence of all sanitary precaution ; con- sequently the soil is polluted, and from data supplied to me by physicians in the interior I know that certain districts are badly infected and the disease is common and widely distributed." 3. Preventive measures. — Mr. Dawson reports on this point: "The government has taken no notice of the disease, nor have any steps, either private or public, been taken to alleviate or eradicate it. In fact little attention has been paid to its diagnosis among those seeking medical treat- ment for obscure cases of pernicious anemia. The fact that a few foreigners were unsuccessfully treated for anemia and later treated for hookworm disease in the United States and entirely cured has called the attention of physicians to the necessity of correctly diagnosing the case." HOOKWORM INFECTION IN FOREIGN COUNTRIES. 33 JAMAICA. 1. Distribution of the infection. — The superintending medical officer of the colony reports that: "Hookworm dis- ease does exist in Jamaica. It has been reported as existing in the following parishes or parts thereof during the last financial year : St. Andrew, St. Thomas, St. Anns, St. Japies, St. Elizabeth, Portland, Westmoreland, Clarendon. It is found chiefly among East Indians, although also to some extent among Creoles ; of some 230 cases reported in one district nearly 100 were among East Indians." 2. Degree of infection. — The population of Jamaica is estimated to be about 862,000, of whom about 15,000 are whites, 16,000 East Indian coolies, 150,000 "colored," 5,000 not. classified, and the rest negroes. Of the East Indian coolies it is estimated that about 50 per cent are infected. The new arrivals bring the disease with them from India. 3. Relief measures. — ^The superintending medical officer reports : "An order has been issued that as a routine prac- tice all admissions to hospitals whose symptoms are at all suggestive of hookworm disease shall be treated therefor. I may say that the Malaria Commission, of which I am a member, is now collecting reports with a view to consider what measures can be taken to alleviate, reduce, or eradi- cate the disease." All coolies suffering from any disease are given free treatment in government hospitals. MARTINIQUE. I. Distribution of the infection. — The Director of the Health Service at Martinique reports : "The disease is prev- alent throughout the country, especially in localities where 3c 34 HOOKWORM INFgCTION IN FOREIGN COUNTRIES. the people drink water from certain ponds." The parasite found is Necator americanus. 2. Degree of infection. — No information available. Thomas R. Wallace, American Consul at Fort-de-France, writes: "The inhabitants of Martinique are just beginning to be informed of the existence of hookworm and the con- ditions resulting from its infection." 3. What is. being done to eradicate the disease. — ( 1 ) The officials of the Health Service are spreading in- formation on the subject by means of printed matter and by public meetings in the country. (2) Regulations have been issued controlling the dispo- sition of night soil. (3) In 1909 a Hygiene and Microbiology Institute was established for the free treatment of transmissible diseases. MEXICO. I. Distribution of infection. — Dr. J. W. Colbert, of the Santa Fe Hospital, New Mexico, reports : "I have made an extensive study of this condition in Mexico, and have found the infection in the states of Lower California, Sinaloa, Queretaro, Guanajuato, Michoacan, Chiapas, Vera Cruz, Guerrero, Oaxaca, and Yucatan." Dr. Ricardoe Manuel, of Mexico, reports infections in Hidalgo, Tamaulipas, Guer- rero, Michoacan, Zacatecas, and Guanajuato. Dr. W. C. Alvarez, of Cananea, Sonora, Mexico, confirms these re- ports as follows : "So far, cases have been reported from almost all the most southern Mexican states from the Isth- mus of Tehuantepec and Yucatan to the states just above the City of Mexico. No case has yet been reported from HOOKWORM INFECTION IN FOREIGN COUNTRIES. 35 the immense northern states of Coahuila, Chihuahua, So- nera, and.Durango. As these states have a more temperate climate and severe winter, owing to their great altitude above sea-level, the hookworm may never get hold on the higher plateaus." 2. Degree of infection. — Dr. Alvarez reports the disease as "very prevalent in the mines of Santa Rosalia, Lower California, and says the whole west coast appears to be heavily infected. Dr. Colbert reports : "I have examined a group of 114 Mexican laborers just received for section work on the Santa Fe Railway, and I found 13 of the men infected with hookworm." Dr. Luis R. Laru estimates in- fection in the mines of the Real del Monte and Pachuca at 50 per cent. 3. Origin and spread of the infection. — Dr. Manuel finds that "all the worms observed so far in Mexico are of the old-world type," and believes that the infection was intro- duced by foreign miners and has spread by the floating min- ing population. Dr. Colbert, on reporting finding 13 in- fected persons in a squad of 114 Mexican laborers, says: "I was informed that between two and three hundred of these men were received in El Paso every day for work on the various railroads of the country, and I believe that these Mexican laborers are responsible for the many cases com- ing to our notice thoughout the West, the Middle West, and Southwest." 4. Relief measures. — Dr. Alvarez writes : "Nothing at all is being done, and, unfortunately, there seems to be no rec- ognition of the disease by the local physicians, who for the main part are very poorly educated, and none that I have met use microscopes." 2,6 HOOKWORM INFECTION IN FOREIGN COUNTRIES. Reports from the public health authorities in many of the States indicate that there is but little local knowledge of the disease. NICARAGUA. 1. Prevalence of infection. — Dr. M. S. Lane, graduate of a medical school in Ontario, Canada, and a practicing physician in Bluefields, reports : "This coast, ot the Depart- ment of Bluefields, is certainly infected. Referring to my notes, I find I have attended the following cases : 6 cases from Cape Gracias and district ; 7 cases from Prinzupulcu and district; 13 cases from Rio Grande and mahogany camps; 27 cases from Pearl Lagoon district; no cases from the town of Bluefields — part of these lived here ; some came from banana plantations on Escondido River, Cukra dis- trict, and Rama Cay. My cases have been all from agri- cultural districts." 2. Degree of infection. — On this point he says: "I am unable to answer this question intelligently, not having the proper data, but I should judge that the percentage of cases is small." 3. Relief measures. — "Only what the individual physi- cians of Bluefields do in treating individual cases and advis- ing as to sanitation and prophylaxis. There is no health board here." PANAMA. I. Distribution of infection. — The infection is general throughout the Republic of Panama. Prevalent among agri- cultural classes and natives in general ; both the new-world and the old-world species present. HOOKWORM INFECTION IN FOREIGN COUNTRIES. 37 2. Degree of infection. — Alban G. Snyder, Consul Gen- eral at Panama, reports: "Infection general and to the ap- proximate degree of 20 per cent." 3. What is being done to alleviate or eradicate it. — The cases which come to the hospital are being treated. Beyond this nothing is being done by public or private agencies. PARAGUAY. I. Prevalence of hookworm infection. — The following letter addressed to Cornelius Ferris, American Consul at Asuncion, gives our only available information on the sub- ject: ' "In fulfillment of my promise this afternoon, I beg to confirm the information which I gave you, that hookworm disease is very prevalent in this, country. Since 1865, when the tyrant, Solano Lopez, commenced the war which lasted until March, 1870, the whole population had been living in a state of semi-starvation. The survivors of that great calamity continued to die off, as during the latter years of the war, from diarrhea, attributed ignorantly by us to the mere want of a healthy food, without suspecting the exist- ence of a parasite in the bowels, until 1880, when it was shown in an epidemic among the workmen in the St. Goth- ard tunnel to be caused by the hookworm or Ancylostoma. * * * With regard to parasitic worms and disease-bear- ing protozoa our field is still unexplored, but if American investigators, who rank in the first line today, could be induced to come with the text of St. Luke 10: i to 16, they would return again with joy like those 70 gospel messengers. "Yours sincerely, Wm. STEWart, M. D." 38 HOOKWORM INFBCTION IN FOREIGN COWNTRIES. 2. Preventive measures. — Mr. Ferris reports: "Nothing is being done to alleviate or eradicate the disease." PERU. 1. Distribution of the infection. — Dr. J. C. Gutierrez, Acting Assistant Surgeon, U. S. Public Health and Marine Hospital Service at Calao, Peru, reports: "Peru is infected with hookworm disease. The territory of Peru is divided into three zones — the Coast, the Sierra or Cordillera, and the Montana or forest region. The latter is the sole region recognized as infected. This zone extends from the slopes of the Cordilleras as far as the frontier of Brazil and Bo- livia, and represents close upon two-thirds of the total sur- face of Peru; the population may be set down as 450,000 inhabitants. At Iquitos there are many cases of hookworm disease. * * * The infection is known only among the agricultural classes. Among the workers in the rnines are seen some cases, * * * but all of them have visited the Montana region, so that it is not possible to ascertain if the patients became infected while working in the mines." 2. Degree of infection. — Dr. Gutierrez reports: "Thirty per cent of the poor in the Montana region are infected with hookworm disease. Among the people of the better class cases are rare." 3. Relief measures. — The same report continues : "Xoth- ing is being done by public or private means to alleviate or eradicate the disease." HOOKWORM INFECTION IN FORi;iGN COUNTRIES. 39 PORTO RICO. 1. Distribution of infection. — When the Porto Rico Anemia Commission, established as a result of Ashfbrd's earlier investigations, took up its work ih 1904 it was found that hookworm infection was present over the whole island ; infection was heaviest on the coffee plantations in the moun- tain regions. The parasite found in Porto Rico is Necator americanus. 2. Degree of infection. — The population of the island was in 1904 about 1,000,000; it was estimated that about 800,000 of these were infected; that among the workers on coffee plantations infection would run as high as 90 per cent. 3. Conditions favdring spread of infection. — The cli- mate is tropical ; the rainfall abundant ; with the exception of a brief season, the ground under the coffee trees is rarely ever dry; the jibaro pollutes the soil around his hut; this soil is covered with a mulch of decaying leaves and is shaded by banana plants and coffee trees; the jibaro goes barefooted the year round and throughout life ; the children under 6 years old usually go unclothed. 4. Relief measures. — The Porto Rico Anemia Commis- sion began systematic work in 1904; since that time more than 300,000 Porto Ricans have been treated. Treatment is given free at anaemia dispensaries, which are maintained at convenient points over the island ; instruction in sanitary measures is given to the people as they are treated and is given to the children in the schools. The Porto Rican gov- ernment is this year (1911) expending $50,000 for the maintenance of the work. 40 HOOKWORM INFECTION IN FOREIGN COUNTRIES. Note." — The laborate reports of the Porto Rico Anemia Commission make it unnecessary to give here a detailed ac- count of the work. SALVADOR. 1. Distribution of infection. — The first case of hook- worm disease reported in Salvador was discovered by Dr. H. Prowe in 1887. In 1889 Dr. Prowe reports that he has seen hundreds of cases in Salvador ; that it is heaviest among the coast Cordilleras and in the central portion; that the east and west sections of the country are for the most part free.* Harold D. Clum, Vice Consul General at San Salva- dor, reports : "The Hospital Rosales, in San Salvador, is the only place in this Republic where the disease has been ob- served and from which it has been possible to obtain any data regarding the degree or spread of the infection. * * * From 1903 to the present year (1911), 1,482 examinations have been made in the Laboratory of Biological Chemistry in this institution. * * * Among the patients found to be suffering from hookworm disease there were persons from all of the fourteen departments and practicalh^ all of the principal towns and cities, as well as many of the smaller vil- lages of the Republic, from which it is evident that the in- fection extends over the entire country.'' He reports infec- tion as heaviest among agricultural day laborers ; as present also among miners, masons, and bricklayers. 2. Degree of infection. — Our present knowledge is not sufficient to justify a statement of the degree of infection in percentages. Dr. Prowe examined at Hospital Rosales 112 *Arch. f. path. Anat. [etc.], Berl., iSgg, v. 7 (3), pp. 458-474. HOOKWORM INFECTION IN FOREIGN COUNTRIES. 4I persons, 65 of whom he found infected. Of 1,482 examina- tions made at the laboratory of this institution from 1903 to 191 1 infection was found in more than 30 per cent of the cases. 3. Relief measures. — Mr. Clum reports that no measures have been adopted by public or private agencies to alleviate or eradicate the disease ; that it has not been regarded as meriting special attention; that comparatively few physi- cians of the country are acquainted with it.* SURINAM, OR DUTCH GUIANA. 1. Distribution of infection. — Dr. E. A. Koch, medical inspector for the colony at Paramaribo reports that hook- worm infection is spread over the whole of the colony ; that it is especially prevalent wherever immigrants are collected in large settlements. The labor on the plantations is com- posed mainly of immigrants from India and Java. This immigration has brought a steady stream of infection into the country. 2. Degree of infection. — An estimate of the degree of infection for every infected area has not been made, but many plantations have been found on which the infection runs as high as 90 per cent. 3. Relief measures. — For the eradication of the disease the following measures have been adopted : a. Sanitary privies have been provided for British Indian and Netherland Indian immigrants. * Mr. Clum derives his information from Dr. Pedro A. Villacorta, in charge of the Section of Demographic Statistics of the Superior Board of Health of Salvador, and from Dr. Jose C. GaSteazoro, a practising physician of the city. 42 HOOKWORM INFECTION IN FOREIGN COUNTRIES. b. A law has been enacted against soil polfution along the roads and on the plantations. c. The distribution of popular literature in the Hindostan- ese and Javanese tongues. d. Treatment in plantation hospitals of all those who are infected, together with periodical examinations Of those who are suspected of being infected. The treatment given is as follows : A purgative in the evening ; on the following morn- ing four to six grains of thymol in pills, followed a few hours later by another purgative. TRINIDAD. 1. Distribution of the infection. — Franklin D. Hale, American Consul at Trinidad, reports : "All over the island. The infection is agricultural." 2. Degree of infection. — Of 25,055 cases of sickness treated at estate hospitals during the year 1909, 994 were classified under the head of hookworm disease, as against 121 cases for the year 1907. 3. What is being done to eradicate the disease. — Noth- ing is being done by the government ; no decisive action has been taken by any private agency. Cases are being treated in estate hospitals. The Agricultural Society at its meeting, June, 1910, appointed Dr. Nasson a committee of one to investigate and report on the disease. VENEZUELA. I. Distribution of infection. — Physicians at Maracaibo report infection in the region south of Lake Maracaibo; Herbert R. Wright, at Puerto Cabello, reports that consular HOOKWORM INFECTION IN FOREIGN COUNTRIES. 43 district as infected ; Isaac A. Manning, American Consul at La Guayra, advises that no study has been made of the geo- graphical distribution of hookworm disease in Venezuela; that a leading physician in Caracas reports having knowl- edge of the general presence of infection throughout the country. Dr. Louis Razetti, of Cara,cas, advises that at the meeting of the National Congress of Medicine next June there will be a report from each state as to general distribu- tion of hookworm infection. 2. Degree of infection. — No accurate data for an ap- proximate estimate. At San Esteban, a village about ten kilometers from Puerto Cabello, the infection is reported as extending to "a great part of its inhabitants." 3. What is being done to eradicate the disease. — Some physicians are treating cases in their private practice. It is . expected that the report from the states at the meeting of the National Congress of Medicine next June will be the beginning of some concerted action for the eradication of the disease. Beyond this nothing is being done. III. ASIA. BAGDAD, TURKISH PROVINCE OF. 1. Prevalence of infection. — Mr. Leonard, American Vice and Deputy Consul at Bagdad, reports: "The Turkish Province of Bagdad is infected with hookworm, but the geographical distribution of the infection within the coun- try is unknown. * * * The infection is agricultural." 2. Degree of infection. — The report estimates the degree of infection at about lo per cent. 3. Preventive measures. — Nothing is being done by pri- vate or public agencies to alleviate or eradicate the disease. CEYLON. 1. Infection. — Both Ancylostoma duodenale and Necator americanus are found in Ceylon. The infection covers prac- tically the whole of the planting districts where Tamil labor is used; it involves also the Sinhalese villages on the con- fines of the planting districts. The disease is more preva- lent on the estates situated in the "low country.'' 2. Degree of infection. — Badly infected estates may have the labor force infected to the amount, of 90 per cent. The committee appointed by the Colonial Secretary to consider measures to prevent the spread of hookworm disease in the island recommends that all superintendents of estates treat all new arrivals with beta-naphthol. "The ground for this recommendation," says the report, "is that the percentage of coolies arriving in the island who are suffering from this 44 HOOKWORM INFECTION IN FOREIGN COUNTRIES. 45 disease in a more or less marked degree is so high that the disease may be said to be practically universal." The com- mittee also recommends the treatment of the whole labor force on infected estates. 3. Infection agricultural. — The infection is confined practically to those who follow agricultural pursuits. ^The number of persons working in mines is very small ; the presence of infection among them has not been ascertained; evidence of the symptoms of the disease among them is absent. 4. Origin and spread of the infection. — It is not known whether the native population of the island was originally infected; it seems to have been at least relatively free from it. Most of it certainly has been brought into the island by the importation of coolie laborers from South India. On March 17, 1910, the Colonial Secretary writes to the chair- man of the Planters' Association : "I am directed by the Governor to inform you that it has lately come to the notice of the government that not only is ancylostomiasis [hook- worm disease] on the increase in Ceylon, but that in dis- tricts where Sinhalese labor is employed upon estates the disease is showing a tendency to spread to the native popu- lation of the island, who hitherto have for the most part been free from it. Recent investigations, as you are aware, have also disclosed the fact that a considerable percentage of the imrnigrant coolies landing in Ceylon for employment upon the estates are already on arrival infected by the disease." 5. Conditions which favor the spread of the disease. — The climate of Ceylon is warm and moist; the coolies on 46 HOOKWORM INFECTION IN FOREIGN COUNTRIES. the estates are massed in "lines ;" the lines are not provided with latrines, and the planters contend that the coolies can- not be made' to use the latrines even when they are pro- vided ; the habits of the coolies are to befoul the soil about the lines and on the estates where they work ; their feet and legs are not protected from contact with the polluted soil. 6. What is being done to alleviate or eradicate the dis- ease. — On February 4, 1909, the English Government sent to the Governor of Ceylon the following dispatch : The Right Hon. the Earl of Crewe, K. G., to Governor Sir H. E. McCallum, G. C. M. M., A. D. C. Ceylon. No. 53- Downing Street, February 4, 1909. Sir: I have the honor to inform you that a committee has been sitting at this office to consider what measures could be recommended for the prevention of ancylosto- miasis in the colonies affected by that disease. 2. This committee has been presided over by Sir Patrick Manson, and has numbered amongst its members Professor J. S. Haldane, F. R. S., who some years ago was commis- sioned to report to the Home Secretary on the prevalence of ancylostomiasis in the Cornish mines. 3. Reports on the existence and treatment of ancylosto- miasis have been obtained from a large number of colonies and have been laid before the committee, who have also taken verbal evidence from a number of medical officers and others who have had experience of the disease. 4. I have now been furnished with a copy of the report of the committee, and in this dispatch I propose to sum- marize the conclusions at which I have arrived after perus- ing it. HOOKWORM INFECTION IN FOREIGN COUNTRIES. 47 5. Having considered the reports from the several col- onies, with the observations of the committee upon them, J recognize that the loss of labor caused by the prevalence of ancylostomiasis is very serious, and affects prejudicially not only the employers of labor, but the community at large. Not only is there serious loss of life, direct and indirect, but also through the invaliding of laborers the charges for hospitals and pauper expenditure are largely increased. This loss is, in my opinion, largely avoidable. Experience has shown that certain simple, well-understood, and inex- pensive measures can be adopted, which, if properly carried out, will reduce the evil effects of anchylostomiasis to a negligible quantity. 6. I think that the colonial authorities have been inclined to exaggerate the difficulties of dealing with this question. They have argued that the complete eradication of an- cylostomiasis is impracticable, and that the cost of pre- ventive measures is prohibitive ; and they have been content, with a few commendable exceptions, to do nothing in the matter. 7. It cannot be too clearlyi understood, however, that, pro- vided that reasonable precautions are taken to prevent the constant reinfection of the laborers, the presence of a small number of anchylostohis, even in a large proportion of the population, may have no appreciable effect. Moreover, no elaborate sanitary appliances are necessary to guard against reinfection on a large scale. For example, latrine accommodation on estates is, I am advised, sufficiently sub- served by a hole or trench cut in, the ground, provided that the contents are covered with earth from time to time. If it is insured that this accommodation will be used by a 1 48 HOOKWORM INFECTION IN FOREIGN COUNTRIES. majority of the laborers, the fact that isolated cases of foul- ing of the soil cannot be prevented is not of material im- portance. The main point is to guard against the fouling of the soil in places where, from the condition of the soil and the presence of numbers of laborers, it is clear that danger is to be apprehended. 8. In these circumstances I think that no hardship can be involved in compelling estate owners, local bodies, and, private persons to take such reasonable precautions as ex- perience has shown will minimize the constant drain on the resources of the community which the existing state of affairs involves. 9. I therefore recommend, for your very careful con- sideration, that — a. Wherever necessary, laws should be enacted en- forcing the provision on estates and elsewhere that numbers of laborers are collected of simple, inexpen- sive, but efficient, latrines, in places appropriate both as regards the convenience of the laborers and the health of the public. b. A penalty should be imposed on persons found avoidably defecating in any place where contamination of the soil or water would be likely to cause risk of infection. c. Each colony should be divided into convenient districts, in each of which should be appointed an in- spector responsible to the local authority, medical officer, or some other authority, who should be charged with the enforcement of sanitary regulations. d. In all schools object lessons on ancylostomiasis should, as far as possible, be given. Leaflets containing simple information on the subject should be distributed periodically. The committee consider that the pamphlet HOOKWORM in]?e;ction in foreign countries. 49 prepared by Dr. Nicholls, of the Leeward Islands, would form a suitable model. e. While the treatment for anchylostomiasis of the whole population is clearly impracticable, arrangements should be made for the distribution from convenient centers, such as schools, post-offices, district nurse sta- tions, etc., of anthelmintics at cost price, with simple directions for use. For this purpose beta-naphthol is the most suitable drug, thymol and other toxic anthel- mintics being used only under medical supervision. 10. It has further been suggested that an inspector- general should be appointed, his salary being divided amongst the several colonies concerned, whose duty it would be to supervise the measures taken for the eradication of ancylostomiasis and to distribute advice and information. The appointment would, it is suggested, be purely temporary in the first instance. While I shall be glad if you will place this suggestion before the Legislature, if a convenient op- portunity should occur, and invite their observations upon it, I wish it to be clearly understood that discussion of this proposal should not be allowed to interfere with the carrying out of the measures which I have advocated above. The appointment of such an officer would, I recognize, involve financial and constitutional questions of some complexity ; and I do not wish that the execution of the more immedi- ately prcaticable measures for the eradication of anchy- lostomiasis should be deferred pending the discussion of these questions. 11. I enclose a short memorandum -in which the reports received from the several ccilonies concerned were sum- marized for the purpose of the committee. Should you desire to obtain further information in regard to any of 4c 50 HOOKWORM INFECTION IN FOREIGN COUNTRIES. the measures referred to in this memorandum I shall be glad to supply you with a copy of any particular report. 12. I request that you will inform me in due course what additional measures for the prevention of anchylostomiasis you propose to take in pursuance of the recommendations made in this dispatch, and that you will include annually in the medical report some account of the progress of those ■ measures. 13. A dispatch in identical terms is being addressed to the Governors of the West Indian Colonies, with the excep- tion of those in which the disease is reported to be unknown. I have, etc. Crewe. On May 26, 1910, the Governor of Ceylon appointed a committee to report on measures for the prevention of the spread of the disease. On the 24th of August, 1910, this committee submitted the following report: Sir: In reply to your letter of May 26 last, appointing us a committee to consider and advise as to the measures to be taken to prevent the spread of ancylostomiasis in the Island, we have the honor to submit the following report. 2. The committee met in Kandy and in Colombo, and examined witnesses both medical and planting. We also received replies to a series of questions which we addressed to gentlemen who were likely to be able to give useful in- formation to the committee on the subject. The evidence and the written answers to the questions which were asked are attached as appendices to this report. 3. The conclusions at which we have arrived on the evi- dence that has been brought before us are summarized in the following recommendations: HOOKWORM INFECTION IN FOREIGN COUNTRIES. 5 1 (i) That all superintendents of estates should treat new arrivals with beta-napthol, followed by tonics ; par- ticulars of the course of treatment recomtnended by the Principal Civil Medical Officer according to the age of the laborer are annexed. The ground fo'r this rec- ommendation is that the percentage of coolies arriving in the Island who are suffering frort^ this disease in a more or less marked degree is so high that the disease may be said to be practically universal. In the rare cases where it does not occur the treatment will not be injurious. (2) Where it is known that ancylostomiasis already prevails on estates, superintendents should treat the whole labor force in convenient batches in a similar manner. We have ascertained that coolies do not ob- ject to the treatment, which can be carried out without greatly interfering with the labor force. (3) When any case of anchylostomiasis occurs amongst laborers admitted to hospital, the medical officer should notify the employer. This is for the purpose of informing the superintendents who may pre- viously have been in ignorance of the existence of the disease on their estates, in order to enable them to take action forthwith. (4) The drugs required for the treatment should be issued at cost price from the Civil Medical Stores. Where estates have dispensaries and are therefore al- lowed a small sum per cooly for medicines, we recom- mend that the drugs required for the beta-napthol treat- ment may be used for Singhalese as well as Tamil laborers' up to the limit of the present capitation grant for free drugs for Tamil coolies. Under existing con- ditions employers have to certify that medicines have been used for their Tamil coolies only, and any drugs required for Singhalese laborers have to be paid for, even though the limit allowed for free medicines has 52 HOOKWORM INFECTION IN FOREIGN COUNTRIES. not been reached. It is highly desirable that facilities for treating Singhalese should be granted, as otherwise they may be the means of introducing the disease into their villages, where it has hitherto been almost un- known. (5) Medical officers in charge of districts should report to the Principal Civil Medical Officer, through their immediate superiors, the prevalence of anchylosto- miasis in a severe form on any estate. In such cases the Principal Civil Medical Officer should be empow- ered to send an officer of his Department to inspect, . report, and make recommendations for combating the disease. If the Principal Civil Medical Officer approves these recommendations, they should be communicated to the superintendent with a view to their adoption. Where these recommendations have not been carried out at the end of three months. Government shall be empowered to enforce the Principal Civil Medical Officer's recommendations at the expense of the estate. (6) With regard to the question of the improvement of sanitation on estates, we recommend that every set of lines and its immediate surroundings should be cleaned and swept once every day. All sweepings should be burnt or buried. The evidence tended to show that more line sweepers should be employed. At least 12 feet clear of all vegetation must be maintained round the lines. Stone, brick rendered in cement, or cement concrete drains should be constructed to carry off rain from the roofs and from the immediate vicinity of the lines. The immediate vicinity of the lines should be on a lower level than the floor of the lines and slope downwards from, them, with the object of keeping the ground surrounding the lines as dry as possible, as the hookworm flourishes in damp earth. All excreta de- posited within so feet of the lines. should be removed daily and buried by the sweeper. HOOKWORM INFECTION IN FOREIGN COUNTRIES. 53 (7) At all bathing places, whether at spouts, wells, or riverside, there should be stone or paved platforms with a properly constructed run-off drain where nec- essary. This is with the object of preventing the reinfection of coolies through the feet when standing on damp earth. Wells for bathing and wells for drink- ing water should be kept separate. (8) To prevent the contamination of the water sup- ply for drinking purposes, closed iron piping is strongly recommended. Open coffee spouting should be con- demned. Wells should be lined with brick pointed with cement and have parapet walls, and a surrounding platform 4 feet wide of stone paving, cement concrete, or brick cement rendered, and a surrounding drain to conduct the waste water away. Wells for domestic and drinking purposes should be covered and provided with a pump. (9) Whilst recognizing the great importance of latrines on estates, we are forced to the conclusion from the evidence given that it is not at present advisable to recommend their general compulsory adoption, but we would urge on all employers of labor the desirability of establishing them especially for bungalow coolies, factory coolies, school children, and Public Works De- partment lines. (10) The attention of agents, visiting agents, and managers of estates should be invited to the recom- mendations of the committee, and they should be espe- cially requested to do all in their power to give effect to them. (11) The question of the segregation of newly- arrived coolies has had our careful consideration, but we do not consider that it would be practicable. Great delay would be involved thereby, and the recommenda- tion of the general treatment of all new coolies should, in our opinion, fully suffice. 54 HOOKWORM INFECTION IN FOREIGN COUNTRIES. 4. The committee are confident that the adoption of the measures which have been recommended above will prevent the spread of the disease without disorganizing the labor force of the Island, and without involving much unneces- sary cost to the employers of labor. We have, etc. H. L. Crawford. W. H. Jackson. Allan Perry, M. D. Joseph C. Dunbar. F. H. Layard. Herbert K. Hillyer, Sec'y. AuGusT-24, 1910. Under date of June 7, 191 1, Dr. Perry of this committee advise that: leaflets have been sent to employers of immi- grant labor; special superintending medical officers are to be engaged to report on the sanitary condition of estates with particular reference to hookworm infection and disease. A legislative enactment has been drafted to be presented to the Legislative Council at an early date. CHINA. I. Prevalence of the infection. — i. Swatow District. The Swatow District comprises the northeastern portion of Kuangtung Province. Population seven or eight millions. Occupation agricultural. ' ( 1 ) Distribution of infection. — Infection throughout the district; most severe among the farmers. (2) Degree of infection. — Dr. G. Duncan Whyte of the English Presbyterian Mission places the infection for the HOOKWORM INFECTION IN FOREIGN COUNTRIES. 55 whole population at 54 per cent ; for the farming population at 74.5 per cent. ' Estimate made on basis of microscopic examination made at hospital. 2. Ngan-hoe Province. — (i) Distribution of infection. Wilbur T. Gracey, American Consul at Nanking, reports: "This infection is generally distributed throughout the rice farming and gardening areas of the Yangtze River valley, to the definite knowledge of American physicians resident here." (2) Degree of infection. — Mr. Gracey states that of 500 persons recently examined 24.6 per cent were infected; of this 500 only about one-half were farmers. For a group of 51 farmers recently examined the percentage of infec- tion is 72.8; for another group of 40 farmers the infection is 76 per cent. 3. Chekiang and Kiangsu Provinces.— This report covers the whole of Chekiang Province and that part of Kiangsu Province south of the Yangtze River and east of 119 de- grees east longitude. (i) Distribution of the infection. — Amos P. Wilder, American Consul at Shanghai, writes : "I have obtained the opinions of foreign doctors in many parts of this district and in every case the reply is definitely made that infection exists throughout the district." (2) Degree of infection. — There has not been enough investigation to give a basis for an approximate estimate of the degree of infection; some of the doctors on basis of general observation place it at from 5 per cent in the cities to 25 per cent among farmers. One doctor who has made many examinations of faeces reports about one out of every ten infected. 56 HOOKWORM INFECTION IN FOREIGN COUNTRIES. 4. Sze-Chuen Province. — (i) Distribution of infection. Albert W. Pontius, American Consul at Choong-king, re- ports : "The existence of hookworm infection is universal throughout the Province, and is fairly evenly distributed." (2) Degree of infection. — Consul Pontius reports: "Out of 1,000 examinations in the M. E. Mission Hospital for Men, 445 had hookworm infection, while only 2 were in- fected among 25 women examined in the mission's women's hospital. The infection is nearly 100 per cent among the agricultural workers." 5. Hoo-Pe Province. — (i) Distribution of infection. — R. B. Mosher, American Consul at Hangkow, reports : "The parasite has been found by nearly all investigators who have systematically looked for it in many mission hospitals throughout Central China. Chiefly Ancylostoma, but Necator has also been identified." (2) Degree of infection. — Statistics not sufficient for more definite statement than that the infection is heavy. 6. China as a whole. — In 1907 the Medical Missionary Association of China organized a department for systematic research to be conducted for three years ; during this period reports were sent in from practically all provinces; the re- sults are summarized in "Diseases of China", by Jefferys and Maxwell, 1910. Of hookworm disease the authors say: 1. That we owe our knowledge of the disease in China to the Medical Missionary Association. 2. That it is one of the most serious factors of disease in the Empire. 3. That the infection is extremely wide-spread through- out the Southern two-thirds of China. HOOKWORM INFECTION IN FOREIGN COUNTRIES. 57 4. That, "excluding the four most northern provinces of Kansoo, Shense, Shanse, and Chili, from which reports are wanting or incomplete, we can confidently affirm that the other 14 provinces are widely infected, the rule being that the further South one travels the more severe the infec- tion. It is also reported as fairly common from Korea, and is extremely frequent in Formosa, 44 per cent, in a series of 1,000 male patients." II. Conditions which favor the spread of the disease in China. — All reports show the infection to be most severe among agricultural workers. Dr. Beebe, an eminent medi- cal authority of the Nanking district, attributes this condi- tion to the fact that the Chinese farmers use human fasces for fertilizer; irrigate growing vegetables with pond water and fasces; and work in the wet soil with bare feet and legs, thus giving opportunity for the larvae to enter through both the skin and the mouth. III. What is being done to alleviate or eradicate the disease. — From all these infected provinces the reports come with one voice : 1. That all mission hospitals are examining and treating all cases that come under their care. 2. That nothing is being done by the Chinese Govern- ment or the Chinese to alleviate or eradicate the disease. The reports call attention to certain difficulties in the way of giving aid on a large scale : 1. "Private agencies would have but a poor opportunity of doing any effective work without the support of the authorities." 2. "No systematic attempts are being made to eradicate the disease; and owing to the universal employment of 58 HOOKWORM INFECTION IN FOREIGN COUNTRIES. liquid manure from night-soil by the agricultural and gar- dening population, it would appear to be a difficult problem." COCHIN CHINA. 1. Distribution of infection. — Dr. F. Noc, military phy- sician, Pasteur Institute of Saigon, conducted a series of investigations covering two years from 1906 to 1908, with a view to discovering the connection, if any, between the very prevalent disease of beriberi and hookworrn infection. He reports* that of jj cases of beriberi examined in 1906, 74 carried hookworm infection; that of 211 cases of beri- beri, all have had hookworm infection; that in these in- vestigations he demonstrated hookworm infection in .2,326 cases ; that his investigations have demonstrated that there is an intimate relation between beriberi and hookworm disease, and that hookworm infection is extremely prev- alent among the Asiatics of Cochin China. Both Ancylos- toma duodenale and Necator americanus are present ; Neca- tor is the prevailing type. 2. Degree of infection. — It is not possible on the basis of data at present available to state the degree of infection in terms of percentages. The records of Dr. Noc would seem to show, and his report repeats with emphasis, that infection is extremely prevalent among the Asiatics of ' Cochin China. 3. Causes favoring the spread of infection. — In addi- tion to the tropical temperature and a high degree of hu- midity. Dr. Noc states that the natives go barefooted and are extremely careless as to soil pollution. * Ann. de I'lnst. Pasteur, Paris, 1908, v. 22 (11), 896-916, 956. HOOKWORM INFECTION IN FOREIGN COUNTRIES. 59 4. Relief measures. — No report on this subject. INDIA. 1. Distribution of infection. — The entire area of India seems to be infected with hookworm. It is most prevalent in Bengal, Eastern Bengal and Assam. Infection is heavy among the Tamils of Southern India. Both the old and the new world species are present. 2. Degree of infection. — It is estimated that from 60 to 80 per cent of the inhabitants of India harbor the worm to a greater or less extent (C. P. L,ukis, Surgeon General I. M. S.). In 1903, Surgeon Major Edwin Dohson, at Dhubri, As- sam, selected for examination 547 of the more healthy looking immigrant coolies from all parts of India. Of the 547 examined 454 were infected. His record of hundreds of examinations of prisoners, immigrants, patients in hos- pitals, laborers in various occupations shows the infection to range from 60 to 80 per cent and to be spread over all parts of India. (Indian Medical Gazette, 1892, 1893, 1900, 1904, 1906.) The Government Medical Inspector for British Guiana reports that of the Indian immigrants to that country for the year 1909, 74.44 per cent were infected. A shipload of Indian coolies just arrived at Durban, Natal, in 1908, showed on examination an infection of 93 per cent. Dr. C. A. Bently reports finding in Assam only one cooly out of 600 who did not show infection. Dr. Dobson found 75 per cent infection among the newly arrived coolies at Dhubri. 6o HOOKWORM INFECTION IN FOREIGN COUNTRIES. 3. India a center of infection. — From the Indian Penin- sula a Constant stream of infection is going into Assam, Ceylon, Southeast Africa, British Guiana, Dutch Guiana, Jamaica, and all countries that are importing cooly labor. 4. Conditions which have favored its spread in India. — High temperature, extreme moisture, shade; a dense popu- lation, the habit of polluting the soil universal and per- sistent, feet and limbs unprotected the year round. 5. What is being done to alleviate or eradicate the disease. — A considerable amount of work has been done by medical officers in India; the results of their investigations have been published in the Indian Medical Gazette and the British Medical Journal. In 1890 the Government had made a special report on Kala Azar and Beriberi in Assam and in 1897 a report on epidemic malarial fever in Assam, both of which involved the subject of hookworm disease. Under date of June 15, 191 1, Surgeon General C. P. Lukis writes: "From these papers it will appear that from 60 to 80 per cent of the inhabitants of this country harbor the worm to a greater or less extent. * * * j have at pres- ent no information available as to the work being done by public or private agencies to eradicate the disease beyond the extension of sanitary measures for the prevention of faecal contamination of the soil, the protection of the feet and the treatment with thymol, the eucalyptus oil mixture, or beta-naphthol, of such patients who may attend hospital." The American Vice Consul, C. B. Perry, writing under the same date, says: "Nothing is being done by Governmental agencies to alleviate or eradicate the disease except the usual sanitary measures for the prevention of fsecal con- tamination of the soil and hospital treatment of incapacitated HOOKWORM INFECTION IN FOREIGN COUNTRIES. 6l patients. * * * The conclusion that I have arrived at is that although widely prevalent in India, the disease is not considered of a dangerous nature and no special steps have been deemed necessary as yet to combat it.'' JAPAN. I. Distribution of the infection. — Surgeon Fairfax Ir- win, of the U. S. Public Health and Marine-Hospital Serv- ice" at Yokohama, reports that the infection is present to a greater or less extent in every prefecture of Japan; that the infection is present both in mines and on the surface ; that it is most frequent among farmers. Special local re- ports definitely locate infection in the following prefectures : 1. Kyoto Fu. — ^The disease found in almost every part of the prefecture. 2. Shiga Ken.- — Only a few isolated cases in remote parts of the prefecture. 3. Naru Ken. — Number of cases not very many, but dis- ease is spreading. 4. Kochi Ken. — 770 cases reported for 1910. 5. Gifu Ken.— Infection in some parts of prefecture among agricultural workers. 6. Toyama. — Disease held in check by preventive meas- ures. 7. Nagano Ken. — In 1909, there were 1,843 deaths from the disease; for 1910 the deaths number 1,893. 8. Ishikawa. — Badly infected; deaths in 1910 due to this cause 1,325. 9. Shidzuoka. — From 1907 to igdg, reported 8,419 suf- ferers from this disease. 10. Akita. — Infection not heavy. 11. Aomori. — Disease exists; under investigation. 12. Ibaraki. — Few cases observed. 62 HOOKWORM INFECTION IN FOREIGN COUNTRIES. 13. Niigata. — Infection light. 14. Tochigi. — Infection light. 15. Osaka-fu. — Isolated cases. 16. Hyogo Ken. — Cases among farmers and some in mines. 17. Wakayama Ken.— 1,130 cases reported for 1910. 18. Hiroshima Ken. — Cases observed in all the counties. 19. Tottosi Ken. — Disease found in every part of the prefecture. 20. Shimane Ken. — Isolated cases in every part of the prefecture. 21. Okayama Ken. — Disease found in every part of the prefecture. 22. Yamag^chi Ken. — Disease present in every part of prefecture; cases reported for 1909, 482. 23. Kanagawa. — Disease believed to be limited to miners and agriculturists. The following tabular statement from report for the prefecture of Yamaguchi is instructive : Number of Cases of Hookworm by Occupation. 1907. 1908. 1909. Occupation. < * > / ''- ^ , ' \ Male. Female. Male. Female. Male. Female. Government or public service 11 ... 22 2 23 Scientific 35 8 47 24 37 32 Medical I Agricultural 140 81 201 103 155 95 Commercial 40 33 47 34 45 20 Manuf actural 5 i 9 4 2 Fishing ... ... ... ... I Shipping 2 I ... ... 2 Mining ... I Laborers 6 ... 5 ... 4 All others ig 32 21 48 15 48 258 156 354 ^11 285 IQ HOOKWORM INFECTION IN FOREIGN COUNTRIES. 63 2. Degree of infection. — Lack of systematic investiga- tion makes it impossible to approximate the degree of in- fection. From the prefecture of Tosa 770 cases are re- ported for 1910; Nara-ken reports an estimated infection of about S per cent of the population. The fact that in- fection is present in every prefecture would indicate a heavy infection in localities where conditions are most favorable. Rice growing in the absence of strict sanitary regulations would seem to supply conditions for a heavy infection. The following exhibit is a rough index to the prevalence of the disease : Number of Cases of Hookworm .by Cities and Counties. City 1907. 1908. 1909. cr , • V , * ■ ^ , * , county. Male. Fem. Total. Male. Fem. Total. Male. Fern. Total. Oshima 2 ... 2 2 i 3 2 ... 2 Kuga 4 3 7 6 3 9 12 9 21 Kumage ...i i 2 2... 2 2 2 4 Tauno 7 3 10 8 4 12 10 6 16 Saba 11 6 17 16 8. 24 14 10 24 Yoshiki 103 65 168 143 93 236 104 78 182 Asa 40 24 64 56 36 92 34 SI 85 Toyo-ura . . 9 6 15 13 6 19 9 7 16 Mine 29 13 42 39 25 64 32 20 52 Shimonoseki 12 8 20 9 4 13 9 2' 11 218 129 347 294 179 474 228 185 415 3. Relief measures. — Dr. Irwin reports : "For the eradi- cation of the disease some effort is being made. In Hyogo an attempt is being made to improve the general sanitary conditions by the construction of water closets and drains and improving the water supply. In some places lectures on the subject are being given." Some of the local reports state that persons found infected are being treated with 64 HOOKWORM INFECTION IN FOREIGN COUNTRIES. thyme made. thymol. No comprehensive, systematic effort is being mn Ho JAVA. 1. Distribution of infection. — Dr. J. J. Kunst, army physician at Ambarawa, Java, estimates that infection is very widespread throughout Java and the Archipelago.* Dr. A. J. Salm reports a series of investigations which demonstrate infection throughout Java and the Archi- pelago, f Javese immigrants on plantations in Dutch Guiana are found heavily infected. J 2. Degree of infection. — The following investigations may serve as an index to the distribution and degree of infection : (i) Dr. J. J. Kunst: a. At Ambarawa, middle Java, demonstrated infection in a nine-year-old boy, European, who had lived in the country only eight months. b. Examined, 140 natives from villages throughout Am- barawa district ; infected, 20 per cent. (2) Dr. A. J. Salm reports :f a. Dr. Erni in 1896 found that 67 per cent of the native employees on a tobacco plantation at Deli were infected; of these 10 per cent to 15 per cent were severely anemic. b. Dr. Van Steeden at Sawah Loento in 1901 examined the convicts in the government mines to which are sent convicts from the whole Archipelago who are condemned to forced labor from five to twenty years. Of 52 examined * Janus. Haarlem, 1910, v. 15, pp. 221 fol. t Gaz. hebd. d. sc. med. de Bordeaux, 1904, v. 2$, p. 164. t Dr. E A. Koch, correspondence. HOOKWORM INFECTION IN FOREIGN COUNTRIES. 65 51 were infected. He concluded that the whole Archf- pelago was heavily infected. c. Dr. Steiner at Soerabaia examined the prisoners who passed through that place on their return home. Examined, II ; found infected, ii. He found infected 24 convicts who had not worked in the mines. d. Dr. Van der Meer, physician who succeeded Dr. Van Steeden at Sawah Loento: Examined, 273 convicts who had arrived there as miners ; found infected, 254. e. Dr. Benjamins at Samarang: Examined, all patients in his hospital, 100 in number; found infected, 70. Many of these were natives who had not worked in the mines. /. Dr. Klaasen found infected 50 natives of Java who had just arrived from Borneo. Of these 2 were extreme cases; one had 20 per cent hemoglobin;, the other 12 per cent hemoglobin. 3. Relief measures. — Dr. Van der Meer recommends the following measures for the mine operators : 1. Supply the mines with latrines. 2. Do not eat during working hours. 3. Provide lavatories above ground and have all workers on leaving the mines clean themselves. 4. In newly opened mines work only persons who are not infected. For the general population Dr. Salm recommends that all people drink only pure water ; that they avoid especially water of open streams. He is convinced that drinking im- pure water is the main source of infection ; this on the ground that the natives by established custom defecate in running water. Sc 66 HOOKWORM INFECTION IN FOREIGN COUNTRIES. KOREA. 1. Distribution of infection. — Dr. O. R. Anison, in charge of the Severance Hospital at Seoul, reports that the country is infected ; that the full extent of the geographical distribution is not yet known ; that his own judgment is that it is distributed throughout the whole country. Dr. Weir, of Chemulpo, reports finding infection in patients from all parts of the country. 2. Degree of infection. — Dr. Weir, who has examined the faeces of a large number of people sick and well with a view to discovering hookworm infection, says that 50 per cent of all cases examined were found infected with hook- worm. Of all those infected, about 70 per cent were farmers. 3. Preventive measures. — ^The American Consul-Gen- eral at Seoul, through whose efforts the above facts were secured, reports that no public measures have been adopted for the relief or prevention of the disease ; that nothing has been done by private agencies save the treatment of cases that come to the doctors. The subject has been taken up by the Korean Medical Missionary Association. MALAY STATES. 1. Distribution of infection. — Infection is prevalent over entire area of Federated Malay States. It seems heaviest among the Tamil laborers on rubber estates; found also among Javanese and Chinese laborers. The Tamils from India constitute three-fourths of the laborers on estates. Both Necator americanus and Ancylostoma duodenale are found. 2. Degree of infection. — Dr. W. L. Braddon, State HOOKWORM INFECTION IN FOREIGN COUNTRIES. 6/ Surgeon at Seremban, reports : "I am able to affirm that it is to one single disease that almost all the mortality and sick- ness of the Tamil laborer is either directly or indirectly due. That disease is ancylostomiasis."* During 1908 he exam- ined 2,000 sick Tamils in estate hospitals and reports: "There was no single one of these coolies who was not affected by ancylostomiasis." At several estates he found "that 60 per cent of the coolies at work were in an advanced state of hookworm disease, and that in all cases examined anemia from the same cause was in some degree present." These facts were presented to the Government as indicating the severity of the disease throughout Negri Sembilan. "There is no reason to suppose," continues the report, "that it is any less prevalent in the other states of the Federation." Dr. A. T. Stanton, bacteriologist,- Institute for Medical Research, reports the following findings :f a. Estate Hospital in Negri Sembilan. — Examined, 152; percentage infected, 56. b. Rubber estate in Selangor, No. i. — The place enjoys the reputation of being a "very healthy estate." Number examined, 158; all at work; percentage infected, 25. c. Rubber estate in Selangor, No. 2. — Considered un- healthy chiefly on account of malaria. Number examined, 64; percentage infected, 53.7. d. Rubber estate in Selangor, No. 3. — Recently opened up. Number examined, 114; all at work on day of examination; percentage infected, 31. Dr. E. Naggiar Graham, medical officer. Lower Perack, reports these findings :J * "The Prevalence of Ankylostomiasis in Ceylon," XV, 1910, p. 20. t Ibid., pp. 21 and 22. t J. Trop. M., Lond., 1909, v. 12 (22), p. 333. 68 hookworm infection in foreign countries. Teluk Anson Hospital. Number Percentage examined. infected. May, 1910 74 54 June, 1910 62 61 July, 1910 98 47 August, 1910 82 57 Estate: S.W 250 68.8 N. S 26 73 Dr. Graham estimates that more than 50 per cent of the entire population is infected ; that the disease is of great economic importance to the rubber industry. 3. Conditions favoring spread of the disease. — In ad- dition to favorable climatic conditions, Dr. Graham reports that drains are very numerous on the rubber estates; that the laborers defecate in these drains; that they use these drains for bathing purposes and frequently drink from them. 4. Relief measures. — The Government has sent a letter to meinagers of estates directing attention to the steps to be taken to prevent the spread of infection. Cases are treated in estate hospitals. Measures so far adopted seem altogether inadequate. PHILIPPINE ISLANDS. I. Distribution of infection. — Systematic survey of the Islands has not been made ; infection has been demonstrated at Manila, Taytay, Las Pinas, Cagayan Valley and other points in Luzon; on the islands of Samar and Cebu. In- vestigations thus far made indicate that infection is general over the Islands. Dr. C. L. Cole reports* that hookworm * Mil. Surg., Carlisle, Pa., 1907, v. 21, p. 298. HOOKWORM INFECTION IN FOREIGN COUNTRIES. 69 disease is one of the moost prevalent diseases found in the Islands ; that examinations indicate a very widespread in- fection; that infection among the enlisted men in the army causes great loss of time. 2. Degree of infection. — Systematic investigation has been made at many different points with the following findings : a. Manila, Bilibid Prison ; Garrison, 1908. Exam- ined, 4,106 adults; infected, 52 per cent. b. Manila; Garrison and Llamas, 1909. Examined, 227 women; infected, 15 per cent. Examined, 158 children under 15 years; infected, 11 per cent. c. Taytay, Luzon; Garrison, Leynes, and Llamas, 1910. Examined, 1,000; infected, 11.6 per cent. d. Las Pinas, Luzon; Bureau of Health, 1909. Ex- amined, 6,000; infected: males, 24.2 per cent; females, 8.06 per cent; average, 16.13 P^^ cent. e. Baguio (elevation 4,770 ft.) ; Bowman, 1910. Ex- amined, 100 school children; infected, 32 per cent. By Board for the study of Tropical Disease, U. S. Army, 1910. Examined, adult Igarots; infected, 29 per cent. /. Cagayan Valley, Luzon; Willets, 1911. Examined, 4,278; infected, 54.37 per cent. Adults examined, 1,350; infected, 74.89 per cent. g. Gaudara Valley, Island of Samar; Nichols and Garrison, 1909. Examined, about 1,000; systematic records not kept, infection frequent. h. Danao, Island of Cebu ; Brewer, 1910. Examined, 51 children; infected, 18 to 35 per cent. Many cases heavy. i. Government Hospital for the Insane, District of Columbia; Stiles and Garrison, 1906. Examined, 115 soldiers returned from Philippines; infected, 12.17 per cent. 70 HOOKWORM INFECTION IN FOREIGN COUNTRIES. Note i.- — With the exception of the examinations made by Stiles and Garrison, 1906, and possibly of examination by Willets, the above statistics are based upon the exarnination of only one slide. The use of three slides would materially increase these percentages. 2. Dr. Victor G. Heiser reports* that records of more than 1,000 stools of persons at large show about the same conditions among the general population. 3. Conditions favoring spread of the infection. — In provinces no sanitary precautions are taken; privies and vaults are unknown ; the ground around each house has been contaminated ever since the house was built. Abundant vegetation around the houses furnishes most favorable con- ditions of shade and moisture. The barefooted householder and his family are constantly exposed to infection, f 4. Hookworm disease and the death rate. — Population of the Philippines iit time of American occupation is esti- mated at about 6,500,000; estimated death rate at over 50 per 1,000. At Bilibid Prison, the death rate under lay man- agement was 238 per 1,000. The prison was placed under the management of the Bureau of Health. The usual sani- tary measures reduced the death rate to 70 per 1,000; here it stopped and resisted further efforts. All prisoners over 3,500 were examined for intestinal parasites; infected, 84 per cent; infected with hookworm disease, 52 per cent. After treatment, death rate fell to 13 per 1,000, where it has remained up to the time of the report of 1909, or more than a year. J * J. Am. M. Ass., Chicago, 1909, v. 52 (2) , p. 97. t Dr. C. L. Cole, Mil. Surg., Carlisle, Pa., 1907, v. 21, p. 298. ? Victor G. Heiser, J. Am. M. Ass., Chicago, T909, v. 52 (2), p. 97. HOOKWORM INFECTION IN FOREIGN COUNTRIES. JI 5. Relief measures. — Many systematic investigations have been made to determine the prevalence of infection; cases that come to the regular hospitals are treated ; general sanitary conditions are being improved. No adequate sys- tematic measures have been adopted to relieve or eradicate the disease. The Bureau of Health is awaiting further in- vestigations to determme conditions before organizing relief measures on a large scale. SAMOA. 1. Discovery. — On November 2, 1909, Passed Assistant Surgeon P. S. Rossiter, U. S. N., discovered hookworm eggs in the stool of a Samoan; two days later he expelled thou-" sands of hookworms which were identified as Necator ameri- canus. The discovery was reported to the Governor on December 2, 1909. 2. Prevalence of the disease. — There are on the islands of Tutuila and Manua 42 coastal and 11 inland villages with a total population of 6,667. On the basis of investigations conducted by the special board appointed by the Governor and later investigations by Dr. Rossiter it is estimated that of this population about 70 per cent are infected. For the islands of Upalo and Savaii, German Samoa, the investiga- tion indicates a heavier infection than for the islands of Tutuila and Manua. 3. Conditions in Samoa favoring spread of the infec- tion. — "The soil is everywhere loose and sandy; the rain is heavy and the ground is always moist; the temperature ranges between 70 and 90 degrees F. throughout the year. The natives are extremely- careless of the disposal of fseces. 72 HOOKWORM INFECTION IN FOREIGN COUNTRIES. and in general defecate just beside, if not in, the roads or just outside the houses. A negligible percentage wear shoes, and the native costume; the lava lava, a single strip of cloth about 30 inches wide and 2 yards long, fastened about the waist, permits every part of the body to come in contact with the contaminated soil, for they sit, eat, and sleep on the ground or on mats." 4. What is being done for its eradication or relief. — On December 2, 1909, Dr. Rossiter reported to the Governor of Samoa the presence of hookworm infection on the island and recommended measures for its eradication. The Gov- ernor appointed a special board to make an investigation and report upon the subject. This board reported making the following recommendations : (i) The establishment of a board of health whose orders would have the effect of law. (2) The enactment of a law fixing adequate penalties for disregard of orders or regulations of the board of health. (3) That orders be issued requiring the people of the colony to immediately erect and use the best latrines their ability and resources can produce; that these latrines be at once put under proper inspection ; and that, as necessity de- mands and means and material permit, these temporary structures be replaced with others of approved design. (4) That temporarily the hospital steward of the station ship perform the duties of sanitary inspector, and that the Bureau of Medicine and Surgery be requested to allow this station an additional hospital steward to be permanently assigned to this duty. (5) Estimates were made of the amounts of money re- quired for assisting, where necessary, towns in the construe- HOOKWORM INFECTION IN FOREIGN COUNTRIES. T^, tion of latrines and paying for other work under the board of health. (6) Recommendations were made of sources from which these funds could be secured. The Governor approved these recommendations and ap- pointed a board of health to consist of the Captain of the Yard, the Senior Medical Officer and the Secretary of Native Affairs. The sum of $i,ooo appropriated from the customs fund was made available January i, 19 lo. The board was ordered to prepare for the consideration of the Governor health regulations following the recommendations of the special board together with suggestions looking to- ward the enforcement of these regulations. (Informa.tion supplied by Surgeon General, U. S. N. (See U. S. Naval Medical Bulletin, vol. 4, p. 476.) Under recent date (1911) Dr. Rossiter advises that every inhabitant of American Samoa has been supplied with sani- tary facilities. STRAITS SETTLEMENTS. 1. Distribution of infection. — Dr. Milton Figart, Vice Consul General at Singapore, reports the infection as cover- ing the entire Settlements. Infection, is mostly agricultural; but little mining is done. Both Necator- americamis and Ancylqstoma duodenale are present, Necator predominating. 2. Degree of infection. — Investigations in the Settle- ments have been less extensive and thorough than in the Federated Malay States; Mr. Figart reports the following results of post-mortems at Tan Took Seng and the general hospital : 74 HOOKWORM INFECTION IN FOREIGN COUNTRIES. a. For 1908, number of post-mortems, 1,837; found in- fected, 13.3 per cent. b. For 1909, number of post-mortems, 1,542; found in- fected, 8.3 per cent. c. For 1910, number of post-mortems, 1,600; found in- fected, 10.6 per cent. The general statement is made that infection in Straits Settlements is much less severe than in the Federated Malay States. 3. Preventive measures. — Estate managers are reported as taking some steps toward prevention in the form of better sewage disposal. SUMATRA. 1. Distribution of infection. — Dr. J. Balm, colonial physician at Moeara, Tambesi, reports* that hookworm in- fection is widespread over the Island of Sumatra; that it is found among the natives of the interior who have never left the region and are still living in the savage state ; that con- ditions clearly show that the infection was not introduced by European occupation. 2. Degree of infection. — Dr. Salm made 89 examina- tions at Moeara Tambesi and found an infection of 42 per cent. Of the natives examined 95.5 per cent were infected. 3. Relief measures. — No report on the subject. *Gaz. hebd. d. sc. med. de Bordeaux, 1905, v. 26 (52), p. 6iS- IV. AUSTRALIA. AUSTRALIA. 1. Distribution of infection. — Reports from all parts of Australia indicate that infection is confined mainly to Queensland. In Queensland infection has been demon- strated in nearly all the principal centers on or near the eastern coast. These range, according to the report of I. S. C. Elkington, Commissioner of Public Health for Queensland, from Cairns and Port Douglas in the north to the Tweed River, i,ooo miles to the south. The principal centers of infection appear to be Cairns, Geraldton, Ingham, and Nambour. The disease does not appear to extend far back from the coast. 2. Degree of infection. — It is not possible to estimate accurately the degree of infection from data now available. Dr. Elkington reports that medical inspection of school chil- dren has failed to reveal anything like the results reported from the southern States ; that an examination of the mines of Queensland has failed to reveal any clinical symptoms. Dr. T. F. McDonald reports* the disease as flourishing among the people of Johnstone River district (between Townsville and Cairns) ; that in one school he found go per cent of the children infected ; that there are 5,000 people in this district that infection is present in every square mile of it, and that it is "sucking the heart's blopd of the whole com- munity." He reports a prevalent craving for dirt eating and numerous cases of severe moral degeneration *J. Trop. M., Lond., 1908, v. 11, p. 25. 75 ^6 HOOKWORM INPBCTION IN FOREIGN COUNTRIES. 3. Source of infection and conditions favoring its spread. — Dr. McDonald attributes the introduction of the disease into Australia to three sources : the South Sea Islanders, Arabians, Italians. He describes his district as a jungle of scrub 60 miles square; frost unknown; rainfall 200 inches. 4. Relief measures. — Ankylostomiasis has been a re- portable disease since 1900; leaflets on the subject are dis- tributed among the people ; local authorities are advised on application concerning measures for the eradication of the disease. It is proposed for the coming year to establish at Towns- ville a local staff under the state department of health to conduct systematic investigation of conditions of the disease in north Queensland; the Institute of Tropical Medicine at Townsville will cooperate. V. EUROPE. AUSTRIA. 1. Infection in Austria. — From the end of 1903 until March, 1907, hookworm disease prevailed as an epidemic in the coal fields of northwestern Bohemia, known as the Falk- man and Briix districts. Of 108,149 miners in 519 mines 34 cases of hookworm infection were reported. As a result of decisive action by the government the number of cases de- creased rapidly from August i, 1904, until March, 1907, when the disease entirely disappeared. A few cases were reported among persons not engaged in mines, but these were imported. In all >there were "](> cases and one death from the time the disease was introduced into Austria until the country was declared free of the infection. 2. Measures by which the infection was stamped out. — The Imperial Ministry of Agriculture issued and enforced the following instructions : (i) The mine must be kept clean and the floors of the galleries dry. (2) Timbers of the mine must be whitewashed with lime. (3) Rigid requirement that the workmen use the toilet rooms. (4) An adequate supply of closets must be provided. (5) Toilet rooms must be so constructed that there will be no leakage from the cesspool. (6) Closets must be kept clean and odorless by the use of disinfectants. (7) Mud must be removed from the galleries. n 78 HOOKWORM INFECTION IN FOREIGN COUNTRIES. (8) Only drinking water known to be good must be used. (9) Places must be supplied for washing. Eating with unwashed hands is forbidden. (10) Anemic workmen must be kept under observation by the mine physician and their tools must be examined microscopically at intervals. (11) When workmen from infected districts are engaged their tools must be microscopically examined. (12) Workmen afflicted with hookworm disease must be treated by a physician and must not be allowed to return to work until completely recovered. In 1904 additional regulations were issued by the Ministry of Agriculture, in conjunction with the Minister of the In- terior, to prevent the reintroduction of the disease into Austria. BELGIUM. 1. Distribution of the infection. — The infection exists chiefly among mine workers in the coal pits ; it is found also among the brickmakers of the industrial parts of western and southern Belgium. The principal infection is in the dis- tricts of Liege, Mons, and Charleroi. 2. Degree of infection. — In 1904 the degree of infection among the workmen in the Mons district was 6.56 per cent; of the Charleroi district 14 per cent ; of the Liege district 23 per cent. In 1910 the infection in the Liege district had been reduced to 5.3 per cent. 3. What is being done to eradicate "the disease. — Bel- gium has the situation undet control. The good results at- tained are attributed to the following measures : (i) Obligation for every miner working underground to produce previous to his engagement and before going into HOOKWORM INFECTION IN FOREIGN COUNTRIES. 79 the pit a certificate of recent date showing that he is not in- fected with hookworm disease. (2) Obhgation for the employer to cause a second micro- scopic examination to be made of the workman's stool be- tween the thirtieth and fortieth day after the first examina- tion. (3) Obligation to have periodical examination of all underground workmen on certain dates. (4) Obligatory shower baths. (5) The treatment of all persons found infected till cured. BULGARIA. Up to the present time (1911) no infection has been dis- covered in Bulgaria. The following measures have been ap- proved by Dr. T. Pstrof, Inspector General of Public Health at Sophia, to prevent the importation of the disease into the country : 1. Mine operators are required as far as possible to per- mit none but native workers to enter the mines. 2. In case of admitting foreign workers, especially those who have worked in the mines of Austro-Hungary, a medi- cal certificate from the country from which they came should be required certifying that the person is free from the disease. 3. Every foreign worker, preferably at the time of his admission, should be placed under observation with a micro- scopical examination of his faeces for two days. His clothes should be disinfected. 4. Twice a year submit all mine workers to medical ex- amination and make microscopical examination of their stools for ancylostomiasis. 8o HOOKWORM INFECTION IN FOREIGN COUNTRIES. FRANCE. 1. Distribution of the infection. — Hookworm infection in France is confined to the mining population, the miners in the vicinity of Lyons and St. Etienne, and in the depart- ments of Nord and Pas de Calais. In the mining region of southern France infection has been demonstrated in the de- partments of La Loire, Saone-et-Loire, Puy-de-Dome, Al- lier, Aveyron, and Gard. 2. Degree of infection. — The degree of infection varies from mine to mine; many mines are quite free from infec- tion; others in the same region show an infection rate as high as 61.1 per cent, 64.28 per cent, 73.89 per cent (1908). The average for 2,708 miners examined in the mines of Gard, Tarn, Aveyron, Allier, Puy-de-Dome, and Saone-et- Loire was 7.2 per cent. This included many mines that were not infected. 3. What is being done to eradicate the disease. — Atten- tion was centered on the matter in 1902 by the serious prev- alence of the disease in Westphalia and in the mining dis- trict of Liege, Belgium. From the latter place miners were coming into the coal pits of Nord. In 1903 a semi-ofiRcial investigation and an official investigation in 1904 demon- strated the infection in the mines of Nord and Pas de Calais and pointed to Belgium as the source of infection. Later investigations were made in mining regions of southern- France. The Pasteur Institute at Lille, working under the auspices of the central committee of the coal mines of France, has carried on a vigorous attack from the first. The following practical measures are being carried out : HOOKWORM INFECTION IN FOREIGN COUNTRIES. 8l (i) Every miner before being employed is examined; if infected he is not accepted. (2) The sanitation of the mines by draining, ventilating, and supplying workmen with movable sanitary pails. (3) Sanitary surface privies in the neighborhood of the mines. GERMANY. 1. Distribution of the infection.— Infection exists in Rhineland, Westphalia, and the government district of Aachen (Aix-la-Chapelle). A few cases have been found among the brick workers in the vicinity of Cologne. It is confined to miners and brickmakers. 2. Degree of infection. — Investigations conducted in 1902 placed the infection in certain Westphalian mines at 19.5 per cent, 20 per cent, 34.14 per cent, 40 per cent, 50 per cent, 79 per cent. Since 1903 the degree of infection has been reduced 95 per cent. 3. Measures for the relief and eradication of the dis- ease. — (i) Institutes have been established for the examination and treatment of workmen. (2) Every mine worker in infected mines is examined periodically. (3) Miners found infected are isolated and treated until cured. These measures have reduced the infection 95 per cent since 1903. ITALY. I. Distribution of the infection. — Hookworm disease is distributed over the whole of Italy, Sicily, and Sardinia. 6c 82 HOOKWORM INFBCTION IN FOREIGN COUNTRIES. It is found chiefly among farm hands, clay workers, and mmers. 2. Degree of infection. — Statistics for even an approxi- mate estimate of the degree of infection are not available. The Director General of Public Health at Rome reports: "Ancylostomiasis in Italy is frequent in Sicily and in Sar- dinia; it is rare in other regions." It has been estimated that about 15 per cent of the miners in the district of Pa- lermo take the disease, but the American Consul at Palermo says: "This percentage is rapidly decreasing on account of the energetic measures adopted by both public and private agencies to eradicate the disease.'' The infection in Italy seems to be relatively light. 3. What is being done to eradicate the disease. — The government has adopted the following measures : (i) Free distribution to the working classes of a publi- cation written in simple language and intelligible to the most modest intellects, giving practical advice as to the best methods of preventing and combating the disease. (2) Distribution of circulars to all the prefects of the Kingdom, giving special instructions for the hygiene of workers in the manufacture of bricks and articles from clay. These special instructions are : a. Avoid pools of stagnant water. b. Meals to be eaten outside of work yards and clay beds to prevent infection of food. c. Laborers must wash hands before eating. d. Drinking water to be kept in closed receptacles. e. Prevent soil pollution by providing closets and en- forcing their use. HOOKWORM infe;ction in foreign countries. 83 (3) For the protection of mine laborers all miners are required to be examined periodically and those infected are to be treated. (4) An active surveillance by the marine sanitary officer of all immigrants landing from Brazil. THE NETHERLANDS. 1. Distribution of infection. — Consul-General Listoe, at Rotterdam, reports that government investigation in 1904 revealed the presence of hookworm infection in the coal mines of L,imburg, one of the southern provinces ; that the infection has lately been demonstrated among the brick- makers of southern L,imburg; that no infection has been found among agricultural workers. 2. Degree of infection. — The Government investigation of 1904 showed for the Limburg coal miners an infection of 21.74 per cent. Among the brickmakers the infection is reported at 14.4 per cent. 3. Relief measures. — For the coal mines the Government adopted stringent measures, excluding the infected from the mines. As a result of these measures the infection was re- duced from 21.74 per cent in 1904 to 2.06 per cent in 1907. Regulations now in force provide for: a. The sanitary disposal of all night soil in the mines. b. The prevention of any carrier from entering the mines. c. The free treatment and disinfection of the brick- makers. The worker is reimbursed for wages lost during treatment. 84 HOOKWORM INFECTION IN FOREIGN COUNTRIES. SPAIN. 1. Distribution of the infection. — The Director of Inte- rior Sanitation of Spain, at Madrid, reports : "The country is infected. This malady affects, almost exclusively, the mining districts and is limited to the south of Spain." Rob- ert Frazer, Jr., American Consul at Valencia, reports sur- face inspection in the township of Tabernes de Valldigna. He says : "The area of the infection is about lo miles square. It is a warm, frostless belt, subjected too intensive cultiva- tion and irrigation, and is noted for the production of straw- berries and other early fruits as well as oranges, rice, pea- nuts, and table grapes. Dr. Rafael Pastor has treated five cases of hoookworm during the past two years, all originat- ing from the same small area referred to. Some of the patients were sent to him by local doctors, who had been treating them for acute anemia." 2. Degree of infection. — The Director of Interior Sani- tation reports : "In general the intensity is not great at the present moment, except in the mining region of Linares, , where there are. mines in which the number infected reaches 80 per cent of the total number of workers." 3. Relief measures.-^— On this point the report continues : "The public institutions have done nothing, nor have pri- vate agencies done anything so far as is known. Only Dr. Codina, of Castellani, has called the attention of the public authorities to the importation and gravity of this malady in Spain." SWITZERLAND. I. St. Gothard tunnel epidemic. — The well-known out- break of hookworm disease among the workmen in the St. HOOKWORM INFECTION IN FOREIGN COUNTRIES. 85 Gothard tunnel (1879-1880) attracted public attention and caused the Swiss Government to institute an investigation. This investigation, conducted by Dr. Sonderregger, re- sulted in a system of sanitary regulations which freed Switzerland from the infection and has kept it free up to the present time (1911). 2. Sanitary measures. — These measures, which were rigidly enforced, provided : ( 1 ) That all new tunnel workmen be carefully examined, and that if infected they be isolated, treated, and not per- mitted to go to work until all traces of infection had disap- peared. (2) That adequate sanitary closets be provided and that all workmen be required to use them. (3) That bathing facilities be provided, and that all workmen be required to keep themselves clean. Dr. Cai-riere, Acting Director of the Federal Department of Public Health, adds : "It is due to these precautions that during the building of the Simplon and Lotscheberg tunnels no case of ancylostomiasis was discovered." WALES. 1. Distribution of infection. — ^There is no evidence of infection iji Great Britain outside the tin mines of Cornwall. 2. Control measures. — A special report on anemia in the Dolcoath mine was made in 1902. The following preventive measures have brought the infection under control : .(i) Use of the sanitary pail under ground. (2) Treatment of all infected persons. (3) Education of the miners in preventive measures. 86 HOOKWORM INFECTION IN FOREIGN COUNTRIES. Forty-six Foreign Countries in Which the Infection is Widespread. I. Africa : Area (sq. mi.) Population. 1. Algeria i84,474 4,739.556 2. British East Africa and Zanzibar 640 150,000 3. Egypt 400,000 9,734,405 4. Gold Coast Colony 40,000 474.000 5. Lagos and Yuraba 28,910 1,500,000 6. Natal 42,019 983,1 18 7. Sierra Leone 4,000 76,655 8. Tunis 51,000 1,900,000 II. Americas, The: 9. Antigua 108 35,ooo 10. Barbados 166 195,588 11. Brazil 3,218,130 14,333,915 12. British Guiana 104,000 278,328 13. British Honduras 7,562 37,479 14. Colombia 473,202 3,593,6oo 15. Dominican Republic 18,755 417,000 16. Dutch Guiana or Surinam 46,060 67,128 17. Ecuador 116,000 1,205,600 18. French Guiana 30,500 32,908 19. Guatemala 48,290 1,747,000 20. Honduras 46,250 487,500 21. Jamaica 4,i93 743.ooo 22. Martinique 381 164,000 23. Mexico 767,005 13,570,545 24. Nicaragua 49,200 380,000 25. Paraguay 157,000 432,000 26. Panama 3i,57i 285,000 27. Peru 463,747 2,660,881 28. Porto Rico ■ 3,606 953,243 29. Salvador 7,225 1,006,848 30. Trinidad 1,754 253,000 31. Venezuela 593,943 2,323,527 HOOKWORM INFECTION IN FOREIGN COUNTRIES. 87 III. Asia; Area (sq. mi.) Population. 32. Ceylon 25,333 3,578,333 33. China 4,277,170 426,047,325 34. Cochin China 23,160 2,400,000 35- India 1,766,642 294,361,056 36. Japan 161,198 46,453,249 37- Java 50,554 26,125,000 38. Korea 82,000 10,528,937 39. Malay States 26,500 676,000 40. Philippine Islands 114,326 7,000,000 41. Samoa 181 55,ooo 42. Straits Settlements ii,543 572,000 43. Sumatra 162,310 3,472,000 44. Turkish Province of Bagdad. . . . 54,503 850,000 IV. Austr.^lia: 45. Queensland 668,497 503,266 V. Europe: 46. Italy 110,550 32,475,253 Total 14,464,158 919,858,243 KEY TO MAPS 1 TO 6 ■J|f Presence of infection reported in the published literature on the subject. I Reports received by the Rockefeller Sanitary Commissiou show widespread surface infection. MAP No. I /// v> '">/ MAP No. 2 MAP No. 3 a •■°4 o f^ MAP No. 4 r <::i. Qk -.-A.- i^a*- J MAP No. 5 ^^'^ .« ALAS K A UNITED STATES , •% -, fist; MAP No. 6 VE ''^■jtVBi-.^ R A / ^ THE. ROCKEFELLER SANITARY COMMISSION FOR THE ERADICATION OF HOOKWORM DISEASE THIRD ANNUAL REPORT OFFICES OF THE COMMISSION WASHINGTON, D. C, U. S. A. 1912 s ?H3 A 7 THE ROCKEFELLER SANITARY COMMISSION William H. Welch Simon Flexner E. A. Alderman D. F. Houston P. P. Claxton WiCKLiFFE Rose A dministraiive Secretary 72$ Southern Building Washington, D. C. F. T. Gates Chairman. j. y. joyner Walter H. Page H. B. Fbissell J. D. Rockefeller, Jr. Starr J. Murphy C. W. Stiles Scientific Secretary 24th and E Sts. N. W. Washington, D. C, L. G. Myers Treasurer CONTENTS. Chapter I. — General summary with notes by the Adminis- trative Secretary. Chapter II. — Summary of activities and results by States. Chapter III. — Half-tone illustrations. Chapter IV. — Illustrative letters. Chapter V.' — Report of the Scientific Secretary. EXPLANATORY NOTES. 1. The term "number of persons treated" as used in this report signifies the number of persons to whom treatment has been dispensed. Some persons to whom treatment has been dispensed carry the medicine home but do not talce it. It is clearly impossible to correct this error in the record. We are confident, however, that the number of persons who have thus failed to take the treatment is more than offset by the very large number of persons who get treated by physicians and otherwise and of whom no report is received and no record is made. The number of persons treated as a direct result of the work is much greater than the number here recorded. 2. The number of pefsons reported as treated by physicians is based on reports of physicians to the State Directors. In many cases the physicians have not kept an accurate record and report the number of persons treated for the given period as "about" so many. If in any cases this estimate by physi- cians is an over estimate, the error is offset many times over by the large number of cases treated by physicians who do not report at all. 3. It will be observed that the number of persons micro- scopically examined in making the infection survey does not equal the total number of microscopic examinations made in a State. All microscopic examinations save those of rural children from 6 to 18 years of age are excluded from the reports of the infection survey. 5 6 EXPLANATORY NOTES. 4. It should be observed that the percentage of infection reported as result of the infection survey is not given as the percentage of infection for the population of the county. The degree of infection among rural children from 6 to 18 years of age is, as a rule, much greater than the average infection for the whole population. The purpose of this note is to guard against attempts to generalize too broadly on the basis of these figures. 5. In interpretating the tables giving numbers of persons treated by quarters for the year 1912, it should be observed that in many of the states the number of persons treated by physicians during the whole year is reported at the end of the fourth quarter. 6. Persons who may desire to see how the work was organ- ized and how the various activities were defined and conducted in the early stages of the work are referred to the First An- nual Report by the Administrative Secretary. An account of the dispensary and how its work is conducted may be found in the Second Annual Report. Each state has its own system of records; they are uniform only in the facts recorded. Any person interested may, by writing the State Director in any one of the states, get a complete set of record forms. PERSONNEL. Alabama. — State Health Officer: W. H. Sanders. State Direc- tor: W. W. Dinsmore. Stenographer: John D. Bibb. Laboratory Force: P. B. Moss, A. Trumper, William Henderson. Field Force: J. Frazer Orr, W. W. Perdue, E. V. Caldwell, C. A. Grote. Arkansas. Secretary State Board of Health: Morgan Smith. State Director: C. W. Garrison. Stenographer: Lillie Hill. Field Force: T. B. Bradford, T. M. Fly, E. A. Campbell. Georgia. Secretary and Director of Laboratories: H.F.Harris. State Director: A. G. Fort. Stenographer: Edna Whaley,* C. P. Read,* Elanor Srauss,* Mrs. Hampton. Laboratory Force: C. E. Pattillo, C. H. Dobbs.* Field Force: T. F. Abercrombie, A. W. Wood, C. R. Henry, C. H. Dobbs, S. H. Jacobs.* Kentucky. Secretary State Board of Health: J. N. McCormack. State Director: A. T. McCormack. Stenographer: Miss C. W. Howell. Laboratory Force: Dr. L. H. South,** Laurine Sigmier, Virginia James, Margaret Forsting, Julia Fenwick, Patricia Fen- wick, Alice Hayden, Annie May Frost, Mary Frances Shea, Mrs. Julia Cope, Mrs. M. W. Steele, Mr. Buford Robinson. Field Force: W. W. Richmond, I. A. Shirley, J. S. Lock, j\I. W. Steele. Louisiana. President State Board of Health: Oscar Dowling. State Director: S. D. Porter. Stenographer: Miss E. C. Regan. Laboratory Force: W. H. Seeman, J. M. Bodenheimer. Field Force: G. B. Adams, J. D. Baucum, G. C. McKinney, T. E. Wright. Mississippi. Secretary State Board of Health: W. W. Smith- son. State Director: W. S. Leathers. Stenographer: Fannie May Hargis. Laboratory Force: George Hampton, F. A. Williams, S. R. Humphries, Mrs. Henry Boswell. Field Force: R. N. Whitfield, H. H. Howard, D. D. Gill, (substitute for Dr. Boswell), Henry Boswell, C. C. Buchanan, R. D. Dedwylder. 7 O PERSONNEL. North Carolina. Secretary State Board of Health: W. S. Ran- kin. State Director: J. A. Ferrell. Stenographer: Inez Reynolds. Laboratory Force: W. C. Riddick, Kolbe Curtice, W. C. Jenkins, E. B. Davis, W. S. Tuttle, H. R. Ray, Charles Stephenson, Mrs. C. L. Pridgen. Field Force: C. F. Strosnider, C. L. Pridgen, P. W. Covington, T, E. Hughes, G. F. Leonard, W. P. Jacocks. South Carolina. Secretary and State Health Officer: J. A. Hayne. State Director: J. LaBruce Ward. Stenographer: JNIiss S. D. Pickney. Laboratory Force: J. R. Cain, A. S. Williams. Field Force: F. M. Routh, J. T. Howell, F. D. Rogers, J. A. Riser. Tennessee. Secretary State Board of Health: R. Q. Lillard. State Director: Olin West. Laboratory Force: Herman Spitz. Field Force: W. J. Breeding, T. B. Yancey, Jr., J. B. Lansden, J. M. Lee, J. E. Lacey,* W. P. Robinson. Texas. President State Board of Health: Ralph Steiner. State Director: M. H. Boerner. Stenographer: Grace E. Brown. Lajbor- atory Force: W. E. Huddleston, E. K. Cochran, Merit Reagan. Field Force: Hubert Ferrell, O. H. Judkins, C. H. Brownlee. Virginia. State Commissioner of Health: E. G. Williams. State Director: A. W. Freeman. Stenographer: Inez V. Goddiii. Laboratory Force: J. O. Fitzgerald, C. B. Brown*, F. W. Poindex- ter,* E. G. Gata,* Miss Mildred Martin*, W. R. Hursey,* A. J. Chenery. Field Force: A. C. Fisher, W. A. Brumfield, W. A. Flecker,* H. G. Tarter,* K. E. Miller. *Resigned. **State Bacteriologist. CHAPTER I. GENERAL SUMMARY WITH NOTES BY THE ADMINISTRATIVE SECRETARY. 1. The total number on record of persons treated for hook- worm disease in eleven States for the year 1912 is 238,755. This means the treatment of more than 762 persons a day for every working day in the year. Persons State. Treated. Alabama 1 1,148 Arkansas 3,029 Georgia 17,21 1 Kentucky 23,028 Louisiana 22,885 Mississippi 44,178 North Carolina 57,991 South Carolina 36,1 10 Tennessee 5,103 Texas 7,472 Virginia 10,600 Total 238,755 2. For this service the Commission has expended this year $184,671.60. This means that for every $0.77 expended by the Cojnmission a human being- has been benefited in health and helped to a better scale of living. 3. In getting persons treated, the work shows increase from quarter to quarter throughout the year. The total num- ber of persons treated by quarters is : For quarter ended March 31, 1912. . . 22,724 For quarter ended June 30, 1912 42,956 For quarter ended September 30, 1912. 64,183 For quarter ended December 31, 1912. 108,892 Total 238,755 9 10 GENERAL SUMMARY WITH NOTES 4. The total number of persons treated for hookworm dis- ease in eleven States for the three years is 393,556. This means the treatment of more than 359 persons 'a day for every day since the work began. No. Persons State. Treated. Alabama 34,5o7 Arkansas 8,146 Georgia 26,81 1 Kentucky 23,028 Louisiana 32,314 Mississippi 80,101 North Carolina 1 1 1 ,872 South Carolina 4i>795 Tennessee 8,042 Texas 7,472 Virginia 19,468 Total.; 393.556 5. In getting persons treated the work of the present year shows increase over the records of the two preceding years: Total number persons treated in 1910. . 14,423 Total number persons treated in 191 1. . 140,378 Total number persons treated in 1912. . 238,755 Total for three years 393-556 6. Expenditure per person treated for the three-year period. — For each person treated the Commission expended : For the year 1910 $4.66 For the year 191 1 1.05 For the year 1912 "JJ Average for three-year period 1.02 BY THE ADMINISTRATIVE SECRETARY. II 7. Microscopic examinations. — Positive diagnosis of hook- worm disease is mainly by microscopic demonstration of the eg-gs of the parasite in the stool of the infected person. The total number of such examinations made by the laboratory and field force in eleven States up to December 31, 1912, is 432,464 : No. Microscopic State. Examinations. Alabama 7,6i2 Arkansas 8,798 Georgia 30,400 Kentucky 45,889 Louisiana 14,931 Mississippi 55,732 North Carolina 181,144 South Carolina 17,009 Tennessee 24,459 Texas 10,758 Virginia 35,732 Total 432,464 8. Increase of microscopic work. — In no feature of the work has growth been more rapid or more significant than in the number of microscopic examinations made : (0) The year 1912 shows a steady increase in number of microscopic examinations throughout the year : Microscopic examinations for first six months. . . 110,682 Microscopic examinations for second six months. 216,269 Total 326,95 1 (b) The year 1912 shows a marked increase over the records of the two previous years : 12 GENERAL SUMMARY WITH NOTES Total number microscopic examinations 1910. . . . 14,789 Total number microscopic examinations 191 1. . . . 90,724 Total number microscopic examinations 1912. . . . 326,951 Total for three years 432,464 9. Cause of increase in microscopic work. — This increase in microscopic worli is due to three marked tendencies in the service : (a) The tendency on the part of State and field directors to require microscopic examination as a basis for treatment. In the beginning treatment was given largely on the basis of clinical diagnosis. Experience has shown that in numerous cases the microscope reveals infection where by clinical diag- nosis it would not be suspected ; and that, on the other hand, there are anemias with accompanying symptoms where hook- worm infection is not present. When the microscope shows the eggs there can be no doubt. It has been demonstrated that in some cases even of heavy infection the microscope fails to reveal the eggs. As to pro- cedure in such cases, there is a difference of opinion and prac- tice. The tendency is to make microscopic diagnosis the basis of treatment; in cases of extreme clinical symptoms when the eggs cannot be found, to follow one's best judgment'based on all the evidence present. (b) Another factor contributing to the large increase in number of microscopic examinations is the improvement of methods and increase of efficiency in making these examina- tions. At the beginning of the work the examination of 25 to 35 specimens was regarded as a full day's work. During the present year many of the microscopists without the cen- trifuge have examined an hundred or more specimens a day; BY THE ADMINISTRATIVE SECRETARY. 1 3 one microscopist examining centrifuged specimens made a record of 282 examinations in one day. (c) The third and most significant factor contributing to this increase in microscopic work is the growing tendency on the part of all classes of people to seek examination regard- less of symptoms. In the beginning of the work it was diffi- cult to get people to submit specimens. They were squeamish about it ; or only those who were ill, it was thought, needed to be examined. It is coming to be more and more generally recognized that all persons living in or near infected territory are subject to infection; that the infected person, whether he is ill or not, is a danger to himself, to his family, and to the community; that, therefore, every person living in or near infected territory, regardless of symptoms, should be ex- amined. At the last dispensary that I visited I saw all classes of people coming or sending for containers; collections of specimens were sent in for whole families, and even for whole schools. During the five weeks of the dispensary in that county 29.2 per cent of .the entire population were examined. ID. Preliminary infection survey. — Infection has been demonstrated in 83 counties of Texas; of the 884 counties in the other ten States, infection has been found in 796. No special effort is being made to push the preliminary survey further; it is taken for granted that as the remaining 88 counties are reached in the regular course of the work, infec- tionjn some degree will be found in all of them. II. Definite survey to determine degree of infection. — This survey is based on a microscopic examination of at least 200 children between the ages of 6 and 18, taken at random — that is, without reference to clinical symptoms — from rural 14 GENERAL SUMMARY WITH NOTES districts distributed over the county. This survey has been completed for 230 counties in eleven States. The total number of children examined for the survey in the 230 counties is 158,555, or an average of 689 per county. In number of counties surveyed and in number of children examined per county, the work of the present year shows a marked advance over that of last year: (a) Number of counties surveyed, 191 1 87 Number of counties surveyed, 1912 143 Total 230 (b) Average number children examined per county, 191 1 428 Average number children examined per county, 1912 818 Total 1,246 12. Degree of infection among country school children. — The degree of infection varies from county to county and from community to community within a county. The records show a percentage of infection by counties ranging from 2.5 to 94. Of the 158,555 rural children microscopically examined in 230 counties in 11 States, 78,572, or 50.9 per cent., were found infected. 13. Sanitary survey. — This survey is an inspection of privy conditions at country homes to determine their degree of efficiency in preventing soil pollution. Its methods are described in our second annual report. The survey has been completed in 308 counties. In number of counties surveyed and in number of homes inspected the present year shows increase over the record of last year: BY THE ADMINISTRATIVE SECRETARY. 15 (a) Number of counties surveyed, 1911 125 Number of counties surveyed, 1912 183 Total 308 (b) Number of homes inspected, 1911 43,448 Number of homes inspected, 1912 59,898 r — Total 103,346 14. Degree of soil pollution at farm homes. — For the 308 counties surveyed, the records show a sanitary index* for counties ranging from o to 19.2 on a scale of a possible 100. A total of 103,346 farm homes taken at random in 308 counties scattered over eleven states have been inspected; of these 50,637 have no privy. For the 103,346 homes the sani- tary index, estimated as for a county, is S-7%- No. privies type A at. .100% 151 15,100 No. privies type B at. . 75% 225 16,875 No. privies type C at. .- 50% 106 5, 300 No. prives type D at. . 25% 2,071 51, 775 No. privies type E at. . 10% 50,156 501,560 No. privies type F at. . 0% 50,637 o Total number homes examined. 103,346 590,610 Sanitary index 5-7% 15. The county dispensary. — fThe county dispensary has become the key to the w^ork; with experience its organi- zation has become more definite and its methods of work more effective. Increase of efficiency is exhibited in every item of the dispensary record: *See Second Annual Report, p. 25. tFor detailed account of the county dispensary and its method of operation see Second Annual Report, pp. 18-22. l6 GENERAL SUMMARY WITH NOTES ((() Number of counties making appropriations for dispensaries, 191 1 76 Number of counties making appropriations for dispensaries, 1912 157 Total for two years '...-....... 233 (b) Total amount appropriated by counties, operating 191 1 . . .• $10,799.60 Total amount appropriated by counties, operating 1912 25,743.46 Total for two years $36,543.06 (c) Number counties in which dispensaries were conducted, 191 1 66 Number counties in which dispensaries were conducted, 1912 171 Total for two years 237 (rf) Number microscopic examinations made at dispensaries, 191 1 54,367 Number microscopic examinations made at dispensaries, 1912 272,898 Total for two years 327,265 (c) Number dispensary weeks, 191 1 349 Number dispensary weeks, 1912 963/^ Total for two years 1,312^ (/) Number persons treated at dispensaries, 1911 74,005 Number persons treated at dispensaries, 1912 149,899 Total for two years 223,904 BY THE ADMINISTRATIVE SECRETARY. IJ i6. Dispensary exhibit. — The county dispensary is an educational agency. While examining and treating the peo- ple it is teaching them by demonstration. Its teaching power has been greatly increased this year by the improvement of the dispensary exhibit. This exhibit includes a series of charts ; a series of photographs ; a few striking posters ; speci- mens of grown hookworms ; specimens of other intestinal parasites; a bit of intestine with hookworms attached to the lining ; hookworm eggs under the microscope ; live hookworm embryo under the microscope; cases that have, been treated. Some local person, preferably a local physician, is enlisted to ■ take charge of the exhibit and keep it working continuously throughout the day. 17. Co-operation of physicians. — The physicians have given more effective- co-operation this year than ever before. In addition to their work in treating patients for hookworm disease they have aided in securing county appropriations for the dispensaries; they have prepared for the coming of the dispensary, in many cases supplying the room and equipment for Its work. When the dispensaries have opened in their com- munities they have urged their people to attend; they have collected specimens, brought them into the dispensary for ex-- amination, and supervised the treatment of their people; they have aided at the microscope ; have given lectures at the dis- pensaries and at schools; have taken charge of the dispensary exhibit and kept it working throughout the day. In the last three counties visited in two states I found every physi- cian actively co-operating in the work of the dispensary. At one dispensary point I met ten local physicians who were active all day getting their people in and getting them ex- amined; one of these physicians brought in 40 specimens at l8 GENERAL SUMMARY WITH NOTES one time. In one state, physicians in six counties are re- ported as giving to the dispensary work 492 days of their time and labor without compensation. In some of the States a very large percentage of the physicians are reporting their experience with the disease, although such report must be purely voluntary and a labor of love. In many cases they have written full accounts of interesting cases and have given hearty endorsement of the work in letters for publication. The phy- sicians who are thus active in the work are in it to stay : (a) Physicians reported treating the disease, igii. . . 4,126 Physicians reported treating the disease, 1912. . . 6,857 (b) Number persons physicians report treating, 1911 . 53,167 Number persons physicians report treating, igi2. 75,870 Total . . •. 129,037 18. Co-operation of other agencies. — In no respect has the work shown more encouraging growth this year than in the co-operation of many agencies whose work cannot be tabu- lated. The press, the ministers, the county boards of health and county health officers, county boards of supervisors, state departments of education, county school superintendents and public school teachers — all these have given indispensable aid in the conduct of the work. Without this aid the results ex- hibited in this report could not have been accomplished. Many of these agencies have been helpf-ul from the beginning, but during the year just ended their co-operation, has been more active, more definite, and therefore much more effective. Something of the spirit and value of the service which they have rendered is exhibited in the "Notes on the work ot the year" in the reports by states. BY THE ADMINISTRATIVE SECRETARY. I9 19. Co-operation of the people. — After all has been said the co-operation that has counted for most is the co-operation of the common man. The real purpose of the dispensary is to carry the gospel of sanitation into the homes of the people and make it a living force in their daily lives. The most effec- tive teacher in any community is the neighbor who has been treated. He takes his own specimen to the dispensary ; through the microscope he sees the eggs in his own stool ; as a part of the dispensary exhibit he sees the squirming embryo of the parasite that has destroyed his own vitality ; he takes the treatment; he feels the pulse of a new life; he brings his family and his neighbors to the next dispensary ; he brings specimens from those who are bed-ridden ; he carries the news of cures; he sends infected persons to their family physicians; he influences public officials ; he creates a community sentiment which expresses itself in better laws and large-r appropriations and becomes the basis of permanent sanitary reform. 20. Improvement in sanitation. — To put a stop to soil pollution is at once the most difficult and the most important result to be accomplished in this work. The building of sani- tary privies has not kept pace with getting the people treated ; such rapid change in ingrained habit has not been expected. But that gratifying progress in sanitation is being made is exhibited in the "Notes on work of the year" in the reports by states. Worthy of special note are the co-operation of state and county school officials with the public health agencies in having sanitary privies built at the schools ; the systematic and aggressive activity of the Mrginia, Louisiana and Mississippi State Departments of Health in the interest of general sanitation. The results of definite instruction in 20 GENERAL SUMMARY WITH NOTES sanitation are strikingly exhibited in the following facts re- cently given me by W. L. Moss, Vice-President and General Manager of the Continental Coal Corporation, Pineville, Kentucky : Conditions in the camps. — In June, 191 1, there were in the company's camps about 150 cases of typhoid; cases of bowel complaint were numerous ; hookworm infection ran about 65 per cent ; soil pollution was practically universal ; the wells and springs were contaminated ; flies had free range. What zvas done. — Dr. McCormack, Dr. Lock and Dr. Hen- dren, the camp physician, urged reform. Mr. Moss secured from his board of directors an appropriation of $25,000 for sanitary improvement ; all open wells and springs were filled up ; deep wells from 80 to 90 feet deep were bored, protected, supplied with pumps ; 400 new sanitary closets were built and hundreds of old closets were made over. Results. — During the summer of 1912 and "iip to the time of my visit (October, 1912) there had not been a case of typhoid in the camps ; cases of diarrhoea were reduced to about half; the cases of hookworm disease have been treated. From June, 1910, to June, 191 1, the force of about 1800 men on the company's pay-roll put on the cars about 600,000 tons of coal; from June, 191 1, to June, 1912, the sarne force put on the cars a fraction over 800,000 tons of coal. Mr. Moss stated with emphasis that merely as an economic proposition this $25,000 is the best investment the company has made. BY THE ADMINISTRATIVE SECRETARY. 21 Table i. — Infection Survey, 1912. Xo, counties No. children Number Per ct. State. surveyed, examined, infected, infected. Alabama 12 3,549 2,030 57.2 Arkansas 9 4,i39 2,155 52. Georgia 14 6,375 S 098 79.9 Kentucky 10 23,501 7,021 32.4 Louisiana 10 8 236 4,027 48.8 Mississippi .- 26 20,640 15368 74.4 North Carolina 33 38,381 18,745 48.8 South Carolina 6 2,796 1,310 46.8 Tennessee 10 3,146 1,286 40.8 Texas 4 4,225 2,792 66 1 Virginia 9 6,300 2,814 44.7 Totals 143 121,288 62,646 Table 2. — Sanitary Survey, igi2. ■ Number of Number of counties rural homes State. surveyed, inspected. Alabama 17 3,717 Arkansas . . . , 10 4,735 Georgia 10 3,8oi Kentucky 9 3,986 Louisiana 10 8,000 Mississippi 28 11,124 North Carolina 20 6,555 South Carolina '. 18 4 639 Tennessee 9 2,104 Texas 4 i ,222 Virginia ; 48 10,015 Totals 183 59,898 22 GENERAL SUMMARY WITH NOTES ^ ^ d ^ 1 •z,% 00 to (T! m ^ IN. m 1- o o> vc 1 ro 1 ^ O ro rn t» O) r^s -t CO iN» in 1 fo in \o ^ In. hH -1 - vo Tl- ^- . ^ S ra 00 r6 '\d o\ VO vo ^O in in 1 t-H 1 O 1^ 00 o^ -r o Ht ro O « __; >^§| ro CO \o ro o . r^ r o ^ ^ o\ 3es ri O Ln \o fM I\ rn 1^ . -t VO in 0\ w f"! -^ ro q_ qj ^ ^ ^J 01 VO 00 ^- irj t^r d\ ^5" rn cv in ro -t- ir, 1 ch I " rn ^ n i- ^ CO (^ o " . sr _X Cfl 1— 1 ro VO ^ 01 UO 1^ CO ^ 1 '::? — 1 ^ m f^ ^ in C O 1. \o no A o O -H -r •-- (^ (N o * fN, in c 4^ CO, CO v: o m vo IN. ON O C' ? "^ — ' vo" CO C3\ 00 ^. u ^ in o 00 w ^^ 00 \c en o t^ 01 c c^ <' mi: 0^ '"]' o 1/ ~) "in 01 l^ fO IN, Tf- -C ir > ra O M ■ rn q o\ - oc t ^C 00 in r^f c ^ \o" i_i ro oi liS ro H- 1/ T 0^ 1-1 m H h ^ cJ : s 't^ r J- u rt n J2' C I n 15 t/) o _rt u U rt rt !- J ^ 'to .^ •:£ f 1 u r o H 'rt ^ c c '5 '^ c c >- a. OJ c q. 4 .t < < C '^ J (^ :z IT h e > 1 BY THE ADMINISTR.VTIVE SECRET.VRV. Table 4. — Dispensary Summary, 1912 — Continued. State. No. of counties operating. Duration of campaign. Total appropriated by counties operating. 14 4 17 6 12 28 39 20 19 4 8 72 weeks 13 weeks 108 weeks 3 [ weeks 56 weeks 178 weeks 227 weeks 1455^ weeks 73 weeks 24 weeks 36 weeks $1,475 Georgia Kentucky Louisiana 2,950 1,700 1.463 4,175.56 9,57990 North Carolina Tennessee Texas 1,375 1,200 Totals 171 963^ weeks 25,743-46 Table s'. — Enlistin^^ the Physicians. State. ^ m to ' a . C 3 S c« 2 'O a! ■ (U - 0. o. i2 2 0^ C S c I-i u C I- i- S (u S OJ 3 -3 7= n! tn 3 w :3 ft 3 1- d^ ■s 2; 2; 2 2 2,418- 396 18 2,34 5369 3,600 794 68 3,600 8,028 3,022 477 7 603 5,739 3,708 2,358 66 1,854 16405 2,033 377 3 100 11,863 1,783 905 16 643 8794 1,720 1,145 10 168 8,622 1,113 411 10 1,200 3.200 3,449 940 22 984 8.784 5,789 490 3 30 6,422 2.357 30,992 365 8,658 18 241 560 6,300 9,976 89,526 0'y5 bn rt OJ u. ■^ > t) (U w C OJ r- PL, u Alabama . . . .\rkansas . Georgia . . . Kentucky . Louisiana . , Mississippi . N. Carolina. S. Carolina. Tennessee . Texas Virginia . . . Totals. . . 8.750 406 4.500 608 6,732 974 79,130 1,125 660 t6t 16,456 660 1,337 500 624 I,05T 279 2,500 519 8 goo 194 6,8S7 129,179 U749 821 ,887 ,750 .342 ,201 584 210 62- ;,87o 24 GENERAL SUMMARY WITH NOTES I to (^ s 0, < tn >> 1 (U C^ 4> O "^^ <1J P^ !" Ji u t u in c^ 01 c^ in o\ o ^ oc c 00~ C^ 01 o\ o\ ^ o \o c \s IN. CO -^ o ro OC _o -^ c^ 03 n o\ CO 1-1 ^ t 3 I :3 a MH ^ o « O O o r^ o t^ -^ ^ o 00 CO o rn O a o 00 o fO in a\ ro >- H ^ -^ ^ ^ ^ "tr, en MO ir lO o o IN. o c^ r^ o 01 pz C vo \r . ^O ^ OO To T) pq rt o 1- QJ H H .tj .i2 lO o In . in t 1—1 I-- - o ^ CO o 00 > ^O lO 1- oo o\ fO c ^ in IN. 0\ I-- >, VO VO VO 00 tN. CO 'i OJ cq VO ^i:- *~ t- (U r- o irj - r- r^ ro vo in m i^ o 01 r In. 1- 00 o o in <-0 IN* o in r- > t ^ ■^ • M 01 o 00 & o a ' 6s ^ d oc •^ CS VH o N vd (N z'^ CI 3 rt OJ c • 'T^ t- - P l _:. > a 'to ^ u 0. 4. w 1/ (5 3 c^ £ 'b = 'S tfl ^ * r- ] BY THE ADMINISTRATIVE SECRETARY. 25 bo 3 fcq I to to s < u c 3 n o "-W w cfl V -O u u . .i-N, 00 so ON % ^ \o f^l ,_, ou w l-l M M o\ 01 in CO vo t^ o t-i IN. o\ ^ \n o ON (T) lO 1— I rt en ^ CM U rn CJ n rt bfl 3 m .i2 ^ •¥ o :3 tn c o o 11 < < O M h-l § ^ C/2 H 2 '5 '5b H > 26 GENERAL SUMMARY WITH NOTES H fl) ►J < c u O) 1— 1 - on on )_i n ro N Q in o -f Ol CM (Yl IN. n\ n rx 5 q. ri^ o. of -t vo" in tN o" ^ c^t M rf in ro 01 fce r; fT) n n\ n ro in n! o f^i tN -+ IN. (^ In ^) tN CO r^ 01 -r; 01 IT) C^ IM in O n ^ -t- OO si rn -t 01 VO " . ra 5^ n '-t n W o -+ f^ §8 LO o in ■^ r/) 01 t^ M.'S W 00 t^ ro (M CXJ 00 in 01 -i- vo in in O m n a. I^ ro r^ c-l 00 CO vo O 00 c .o. U U < <; O W ^-1 S » to t-i eg H ;> BY THE ADMINISTRATIX'E SECRETARY. Table q. — Xuinber of persons treated by quarters. 1912, -27 State. March 31. Alabama 361 Arkansas 66 Georgia ^.T^Z Kentucky Louisiana 4o4i Alississippi 2,617 North Carolina... 9,261 South Carolina... 3,669 Tennessee 496 Texas Virginia Totals 22,724 Quarter June 30. endin:; Sept. 30. Dec. 31. Total. 1.359 3,351 6,077 11,148 25 1,492 1,446 3,029 3,338 4,816 7.344 17,211 367 4,658 18003 23,028 6,396 S.364 6,584 22,885 7 395 15.35s 18,811 44,178 9473 17.072 22,18s 57,991 11,122 6,225 15,094 36,110 1,957 1,592 1,058 5,103 1,478 5,994 7,472 1.524 2,780 6,296 10,600 42,956 64,183 108892 238,755 Table 10. — Expenditures, 1912. State. B.v counties. Alabama $1,475.00 Arkansas 64.22 Georgia 2,618.16 Kentucky 1,700 00 Louisiana i ,463.00 Mississippi 3,875.36 North Carolina 8,354.91 South Carolina.... 600.00 Tennessee 771.82 Texas 1,059.97 Virginia 500.00 By state. $2,844.34 4,000.00 2,500.00 3,000.00 5,000.00 234-75 960.10 790.00 By commis'n. $12,135.78 13,243.41 15 726.44 14823.41 14,260.40 19,611.34 19,153.84 14,086.83 16,514.06 4,117.96 13,637.16 Total. $16,455.12 13,307.63 18,987.93 20,523.41 18,223.40 26,486.70 32,508.75 14,921.58 17,285.88 6,138.03 14,927.16 Totals $22,482.44 $19,972.52 fi57,3io.63 $199,765.59 Expenses of Administrative Secretary's office. Expenses of Scientific Secretarys office Expenses of Treasurer's office Special and sundry expenses $22,191.64 4 349.42 55789 262.02 Total expended in 1912 $227,126,56 28 GENERAL SUMMARY WITH NOTES ^ Table ii. — Infection survey by years Xo. counties surveyed. No. children examined. State. 1911. 1912. 1911. 1912. Alabama 2 12 840 3,549 Arkansas 9 9 2,685 4,i39 Georgia 2 14 568 6,375 Kentucky 10 23,501 Louisiana 10 10 3,638 8,236 Mississippi 17 26 9,561 20,640 North Carolina 2r 33 11,466 38,381 South Carolina 3 6 1,188 2,796 Tennessee 13 10 3,271 3,146 Texas 4 4,225 Virginia 10 9 4,050 6,300 Totals 87 143 37,267 121,288 Table 12. — Sanitary survey by years. \o. counties No. rural homes surveyed. inspected. State. 1911. 1912. 1911. 1912. Alabama 7 17 2,562 3,717 Arkansas 11 ID 6,159 4735 Georgia 11 10 4,981 3,801 Kentucky ^. 9 3,986 Louisiana 11 10 6,485 8,000 Mississippi 9 28 2,428 11,124 North Carolina 44 20 13,251 6,555 South Carolina 4 18 2 293 4,639 Tennessee 14 9 2,898 2,104 Texas 4 1,222 Virginia 14 48 2,451 10,015 Totals 125 183 43,448 59,898 Table 13. — Microscopic examinations by years. Number of persons examined in State. 1910. 1911. 1912. Total. Alabama 92 2,640 4,880 7,612 Arkansas 442 3,460 4,896 8,798 Georgia 1,165 7,8i6 21,419 30,400 Kentucky 834 45,055 45.889 Louisiana 79 5,975 8,877 I4.93I Mississippi 1,682 14,75' 39-293 55,732 North Carolina 7,949 37,328 135,867 181,144 South Carolina 85 3 052 13,872 17,009 Tennessee 545 7,876 16,038 24,459 Texas 10.758 10,758 Virginia ,2,750 6,986 25,996 35,732- Totals 14 789 90,724 326,951 432.464 BY THE ADMINISTRATIVE SECRETARY. 29 Table 14. — Dispensaries by years. a. Number of counties in wliich dispensaries were conducted : State. igii. 1912. Total Alabama ' 12 14 26 Arkansas I 4 5 Georgia 2 17 19 Kentucky 6 -6 Louisiana 9 12 21 Mississippi 13 28 41 North Carolina 17 -39 56 South Carolina 4 20 24 Tennessee S 19 24 Texas 4 4 Virginia 3 8 11 Totals 66 171 237 Table 15. — Dispensaries by years — Continued. b. Total amount appropriated by counties operating: State. 1911. 1912. Total. Alabama $2,035.00 $1,475.00 $3,510.00 Arkansas 50.00 200 00 250.00 Georgia 300,00 2,950.00 3 250.00 Kentucky .... 1,700.00 1,700.00 Louisiana 1,150.00 1,463.00 2 613.00 Mississippi ' 2,114.60 4,175.56 6,290.16 North Carolina 4,300.00 9,579-90 13,879.90 South Carolina .... 1,025.00 1,025.00 Tennessee 550.00 1,375.00 1,925.00 Texas .... 1,200.00 1,200.00 Virginia 300.00 600.00 goo 00 Totals $10,799.60 $25,743.46 $36,543.06 Table 16. — Dispensaries by years — Continued. c. Dispensary weeks : State. iOll. 1912. Alabama 83 72 Arkansas 3 13 Georgia 12 108 Kentucky 31 Louisiana 24 56 Mississippi 64 1 78 North Carolina 91 227 South Carolina 38 145/^ Tennessee 19 73 Texas 24 Virginia 15 3^ Totals 349 9^3 J^ Total. 15s 16 120 31 80 242 318 18354 92 24 51 1,312'^ 30 GENERAL SUMMARY WITH NOTES Table 17. — Dispensaries by years — Continued.. d. Microscopic Examinations at dispensaries : State. 191 1. 1912. Total. Alabama 2,640 4,241 6,881 Arkansas 1,859 4.296 6,155 Georgia 3,054 18,434 21,488 Kentucky 22,831 22,831 Louisiana 4,761 8,218 12,979 . Mississippi 13,157 37.994 Si, 151 >Torth Carolina- 17.223 126.106 143,329 South Carolina 1,787 11,782 13.569 Tennessee 7.269 15,141 22,410 Texas 3,428 3,428 Virginia 2,617 20,427 23,044 Totals 54,367 272,898 327,265 Table 18. — Dispensaries by years — Continued. e. Number of persons treated at dispensaries: State. 1911. 1912. Total. Alabama 19,489 5,723 25,212 Arkansas 287 2,208 2,495 Georgia 972 9,456' 10,428 Kentucky 6,353 6,353 Louisiana 5.001 11,020 16,021 Mississippi 15,388 33,977 49,365 North Carolina 29,172 42,132 71,304 South Carolina 2,437 25,270 27,707 Tennessee 665 3,842 4 507 Texas 4,262 4,262 Virginia 594 5,656 6,250 Totals 74,005 149,899 223,904 Table 19. — Number persons treated by physicians by years. State. 191 1. 1912. Total. Alabama ~. 3,870 4,749 8,619 Arkansas 1,500 821 2,321 Georgia 7,228 6,887 i4,iiS Kentucky 15,750 15,750 Louisiana 1,197 5,342 6,539 Mississippi 15,803 10,201 26004 North Carolina 16,709 15,859 32,568 South Carolina i,774 10,840 12,614 Tennessee 666 584 1,250 Texas 3,2io 3,210 Virginia 4.420 1,627 6047 Totals 53.167 75.870 129,037 BY THE ADMINISTRATIVE SECRETARY. 3I Table 20. — Number of persons treated by years. State. 1910 191 1 1912 Total. Alabama 23,359 11.148 34,507 Arkansas 3,330 1,787 3,029 8,146 Georgia 1,400 8,200 17,211 26,811 Kentucky 23 028 23,028 Louisiana 9,429 22,885 32,314 Mississippi 824 35,099 44.178 80,101 North Carolina ■. . 8,000 45,881 57,991 111,872 South Carolina 665 5,020 36,110 41, 795 Tennessee 204 2.735 5, 103 8,^42 Texas .... 7,472 7,472' Virginia 8,868 10,600 19,468 Totals • 14,425 140,378 238,75s 393,556 Table 21. — Number physicians treating the disease by years. State. 191 1. 1912. Alabama 227 406 Arkansas 200 608 Georgia 690 974 Kentucky 1,125 Louisiana 159 161 Mississippi , 786 660 North Carolina I,i95 1,307 South Carolina 100 624 Tennessee 256 279 Texas SiQ Virginia 5i3 i94 Totals 4,126 6,857 Table 22. — Expenditures and treatments by years. Expenditure No. persons, per person Expended. treated. treated. 1910 $67,223.44 14,423 $4.66 1911 149,436.16 140.378 1.05 1912 184,671.60 238,755 .77 Totals $401,331.20 393,556 1.02 CHAPTER II. SUMMARY OF ACTIVITIES AND RESULTS BY STATES. ALABAMA. I. State survey by counties. . I. Infection survey, based on an examination of at least JOO chil- dren between the ages of 6 and i8 years, taken at random from the country : r„,„tv Area in p__,,,.,^;_„ Number Number Perctg. of L,ojnty. Sq. miles, ■t^opul'ition. . examined, infected, infection. Barbour 920 , 32,728 212 141 66.5 Bibb 622 22,791 314 _ 166 . 52 8 Bullock ....... 609 30,196 211 " 80 37.9 Butler 769 29,030 i6s 85 51.5 Choctaw 912 18,483 62s 518 82.8 Covington 1,029 32,124 200 131 65.5 Greene 681 22,717 221 117 52.9 Houston 32,414 200 114 57^0 Madison 806 47,041 220 30 13.6 Marshall 590 28,S53 S8o 292 50.3 Pickens 937 25,055 376 225 59.8 Wilcox 914 33,810 225 131 58.2 2. Sanitary survey, based on an inspection of privy conditions at at least 100 country homes : Type ot Privy. /- i -n I? 17 Total No. County. D E F jn^pg^.a. Barbour i 46 156 203 Bibb 202 41 243 Bullock 178 115 293 Butler 151 49 200 Choctaw 3 88 136 227 Clarke 194 25 219 Covington 122 78 200 Crenshaw 55 1^3 218 Elmore S3 141 I94 Henry 32 189 221 Houston 4 166 58 228 Madison 138 72 210 Marshall 119 107 226 Monroe I47 S3 200 Pickens 106 97 203 Sumter 203 29 , 232 Wilcox 168 32 200 32 ALABAMA. 33 II. Getting the people treated. 1. Enlisting the physioians : (i) Number of physicians in state 2,418 (2) Number of pliysicians personally interviewed 396 (3) Number of lectures to physicians 18 (4) Number of physicians thus reached 234 (5) Number of circular letters sent to physicians 5.369 (6) Number of bulletins sent to physicians 8 750 (7) Number of physicians now treating the disease 406 ■ (8) Number of persons treated by physicians 4,749 2. Getting the people to seek examination and treatment : " (i) Number of schools inspected 147 (2) Number of persons examined : Clinically 23,926 Microscopically 4,880 (3) Number of persons treated by field force : At dispensaries 5-723 At schools 676 (4) Total number of persons treated on record 1I1I48 Work of county dispensaries : Doctor and Amount of county. appropriation. (Dr. Orr.) Barbour $150.00 Crenshaw 150 00 Elmore 150.00 Henry 150.00 (Dr. Purdue.) Bibb 150.00 Monroe 100.00 -Wilcox 100.00 Clarke . . . .- 100.00 (Dr. Caldwell.) Bullock 75.00 Madison 100 00 Marshall 100.00 Sumter Reported (Dr. Grote.) Choctaw Reported Pickens 150.00 $1,475 00 Duration of campaign. 4 J/2 weeks 6 weeks 4 weeks 4 weeks 4 weeks Syi weeks 6 weeks to be open- ed Jan. 1st. 8 weeks 4 weeks 9 1/2 weeks 7 weeks 5>^ weeks 4^/i weeks 72^ weeks Total No. Total No, persons treated. treatm'ts. 546 1,324 38 99 702 2,045 58 129 369 540 316 498 183 208 no 316 125 no 464 148 1285 585 1,902 897 34 ALABAMA. Doctor and Number of persons and times treated, county. I 2 3 4.5 (Dr. Orr.) Barbour .... 546 99 44 13 Crenshaw . . . 1,324 517 181 20 3 Elmore 38 16 4 Henry 99 30 (Dr. Purdue.) Bibb 203 61 42 ID Monroe ..... 369 82 35 12 Wilcox 540 117 30 4 Clarke (Dr. Caldwell.) Bullock .... 183 23 2 Madison ... no Marshall.... 316 104 40 2 2 Sumter 125 23 (Dr. Grote.) Choctaw ... 1,285 488 115 13 I Pickens 585 257 53 2 Totals ... 5,723 1,817 546 76 6 5,723 8,168 4. Laboratory Report: ( 1 ) Number of specimens examined 639 (2) Number of specimens positive, hookworm 244 (3) Percentage of infection thus shown 38.1 (4) Number of doctors sending in specimens 78 5. Summary: ( 1 ) Number of persons examined 27,806 (2) Number of persons treated by physicians 4-749 (3) Number of persons treated by staff: At dispensaries 5,723 At schools 676 (4) Total number of persons treated 1 1,148 III. Educating the people in sanitation. 1. By public lectures: ( 1 ) Number of public lectures delivered 106 (2) Estimated number of persons thus reached.' 12,375 2, Through the schools : (1) Number of teachers in state 9,220 (2) Number of teachers reached by visit 665 (3) Number of teachers reached by letter 389 (4) Number of teachers reached by bulletins 1,600 (5) Number of teachers reached at institutes i!396 ALABAMA. 35 3. By bulletins, leaflets and special literature : (i) Total number of bulletins and leaflets distributed. . .74,354 4. Through the public press : (1) Number of papers in state 235 (2) Number of papers personally visited 63 (3) Number of letters to press 41 (4) Number of articles furnished for publication 136 IV. Notes on work of the year : 1. The total microscopic examinations and home inspections as shown on the report for field men does not tally with the report giving the infection and sanitary surveys by counties for the reason that a number of microscopic examinations and home inspections were made in counties where we did not succeed in completing these surveys ; these incomplete surveys are not herein reported. 2. The State Superintendent of Education has issued in- structions to county school trustees throughout the state that no state funds can be obtained for new school buildings un- less the contract for same shall provide for two sanitary privies to be erected in accordance with plans and specifications fur- nished by the State Board of Health. 3. In the counties of Pickens, Marshall and Madison the county boards of education have issued orders that sanitary privies must be erected at the schools throughout the county. The trustees are ordered to provide for this by taxing each pupil not -more than fifty cents per term. Plans and specifi- cations for these privies are to be furnished by the State Board of Health. In the counties of Barbour, Bibb, Bullock, Choctaw, Cren- shaw, Henry and Sumter, school trustees in many districts adopted official resolutions recommending that their schools be provided with sanitary privies in accordance with the plans urged by the State Board of Health. 36 ALABAMA. 4. It is gratifying to report that county health officers have been more active than ever before, evinced by : (a) Many letters of inquiry as to how they can best assist in the campaign in their county, and asking literature. (b) Publishing of their reports in the county papers, giving the results of the hookworm campaign in their county. (c) Assisting and securing county appropriations. (d) Accompanying field men on county tours. (e) Assisting in conducting dispensaries. (/) Writing letters of endorsement addressed to county health officers in other counties. 5. In every county campaigned this year the doctors have taken more interest and have been more active than ever be- fore. In every instance county societies have rendered indis- pensable service in launching their county campaigns, by res- olutions endorsing the work and by addressing official requests to county courts of commissioners asking for the appropria- tions. The societies have also published in their local papers resolutions calling on the people to take advantage of the op- portunities for treatment and cure offered by their local board of health in co-operation with the State Health Department. 6. Several county societies have arranged programs for their meetings calling for papers and discussions on hookworm disease, and the state campaign for its eradication. • iMany individual doctors have made special trips throughout their communities urging the people to go to the dispensaries for examination and treatment. A number of such physicians have also assisted in conducting the dispensary and making microscopic examinations. 7. Deserving of special mention are two communities in iMadison and Lauderdale counties, respectively, where minis- ALABAMA. -Xil ters and laymen joined in a voluntary Public Health Cam- paign. The local doctors backed up these movements very actively. The State Board of Health co-operated in these local campaigns, several lectures being given and large quantities of literature distributed. 8. School teachers, as usual, have responded with their characteristic zeal and sincere interest to all our requests for their co-operation. They have rendered indispensable service in getting school-children examined and treated. In three communities in Choctavir county, reported by Dr. Grote, three schools closed for the day, the teachers bringing all the chil- dren to the dispensary to be examined. In all instances a recess has been granted to allow the field man to deliver lec- tures on hookworm disease, sanitation, etc. The programs for teachers'* institutes almost invariably call for lectures by rep- resentatives of this department. 9. County courts of commissioners and probate judges de- serve special mention for their cordial support. The appropri- ations asked for have been cheerfully made in every case. In several instances the probate judges, acting for the revenue boards, have volunteered and made additional appropriations, after having seen so much good done by the campaign among the people. In the 14 counties campaigned this year these courts have donated a total of $1,475 to aid the work in the county campaigns. 38 ARKANSAS. ARKANSAS. I. State survey by counties. 1. Infection survey, based on an examination of at least 200 chil- dren between the ages of 6 and 18 years, taken at random from the country : Area in Number Number Perctg. of County. Sq. miles. Population, examined, infected, infection. Ashley 974 25,268 389 213 54.9 Cross 629 14,042 236 102 43.2 Drew 838 21,960 223 62 28.2 Hempstead 722 28,285 526 i97 376 Izard 611 14,561 1,116 685 61.4 LaFayette 524 i3,74i 329 235 28.6 Nevada 610 i9,344 743 486 65.4 Sharp 606 11,688 219 45 20.5 Saline 7So 16,657 3S8 130 33-0 2. Sanitary survey, based on an inspection of privy conditions at at least 100 country homes. Type of Privy. County. E F Total Cross 395 459 854 Hempstead 30S 239 544 Izard 100 537 637 Jefferson 187 227 414 Lincoln 315 242 557 LaFayette 150 337 4^7 Saline 92 144 236 Sharp . . ; 65 326 391 Union 172 206 378 Woodruff 127 no 237 II. Getting the people treated. 1. Enlisting the physicians : (i) Number of physicians in state 3,600 (2) Number of physicians personally interviewed 794 (3) Niunber of lectures to physicians > . . 68 (4) Number of physicians thus reached 3,6oo (5) Number of circular letters sent to physicians 8028 (6) Number of bulletins sent to physicians 4.500 (7) Number of physicians now treating the disease.... 608 (8) Number of persons treated by physicians 821 2. Getting the people to seek examination and treatment : ( I ) Number of schools inspected 377 ARKANSAS. 39 (2) Number of families examined (3) Number of persons examined : Clinically S,ooo Microscopically ' 4^895 (4) Total number of persons examined 9!896 (5) Number of persons treated by field force 2^208 (6) Total number of persons treated on record 3,029 3. Work of county dispensaries : Amount of County. Appropriation. Cross Hempstead $25.00 Nevada 25.00 Izard 150.00 Union Others Hassig-Ellis Drug Co. -do- nated) 5000 Totals $250.00 Amount used. Duration of of campaign. $4.34 S94 53-94 4 weeks 6 weeks 12 weeks 2510 $89.32 22 weeks Number of persons and times treated. 1234 Total No. Total No. County. treated, treatm'ts. Cross 90 80 50 90 220 Hempstead 193 35 23 193 251 Nevada 307 55 25 307 387 Union 376 280 260 376 916 Izard 768 241 68 15 768 1092 Others 474 118 47 474 639 2,208 809 473 15 2,208 3,505 Report of laboratory : (i) Total number of specimens examined 600 (2) Number containing hookworm ova 151 (3) Average per cent, of infection 25.16 (4) Number of other parasites 57 (5) Number of mailing cases distributed 1,125 (6) Number of mailing cases returned 600 Summary: ( 1 ) Number of persons examined 9 896 (2) Number of persons treated by physicians 821 (3) Number of persons treated by staff 2,208 (4) Total number of persons treated 3029 40 ARKANSiVS. III. Educating the people in sanitation. 1. By public lectures : (i) Number of public lectures delivered 190 (2) Estimated number of persons reached 49j883 2. Through the schools : ( 1 ) Number of teachers in state 9 522 (2) Number cf teachers reached by visit 650 (3) Number of teachers reached by Iclrer 2d5 (4) Number of teachers reached by bulletin 10,17s (5) Number of teachers reached at institutes 6,475 3. By bulletins, leaflets and special literature : (1) Total number of bulletins and leaflets distributed.48,102 4. Through the public press : (i) Number of papers in state 290 (2) Number of papers personally visited 7S (3) Number of letters to press 25 (4) Number of articles furnished for publication. . . . 212 IV. Notes on work of the year. 1. The following towns during 1912 have either adopted sewerage or dry bucket closet to some degree, with regu- lations concerning their care, and also have made attempts to improve and protect tlie water supply : Bauxite, Flor- ence, Wabash, Magnoha, Helena, Stuttgart, Paragould, Jonesboro, Conway, Morrillton, Heber Springs, Eureka Springs, El Dorado, Waldron, Mariana, Searcy, Marion, Osceola, Batesville, Forrest City. 2. Return self-addressed postal cards to county superin- tendents, county examiners and physicians, out of sewered districts, requesting information relative to the construction of sanitary toilets for 1912 show reports from 39 counties, and 980 closets constructed therein. Most of the counties reporting are those in which the Commission has done most of its work. In spite of the fact that every effort was made to get a report from every county, the remaining 36" counties failed to respond. I am of the opinion that many ARKANSAS. 4 1 of these closets reported as sanitary are simply constructed with boxes and trap-doors, without being fly-proof. Many of them, however, will measure up to the 75% requirement. 3. As a result of addresses and appeals before various organizations the following actions were taken : The Arkansas State Teachers' Association adopted resolutions endorsing the work and creating a Teachers' Health League in every county in the State. The Arkansas Trav- elers promised hearty co-operation and urged that all hotels in the state build sanitary closets. The Hotel Proprietors' Association promised to comply as rapidly as possible and to aid the State Board of Health in passing a suitable health bill. The Arkansas Medical Society renewed its pledge of loyalty and commended the work. The Arkansas Federation of Women's Clubs enthusiastically endorsed the work and created Health Committees in every county where they have organizations, and are actively aiding in every way possible and are doing all in their power to force the passage of a satisfactory health bill. Various local societies and clubs have shown the same uniform courtesy and expressed appreciation of the good work being done. 4-2 GEORGIA. GEORGIA. I. State survey by counties. I. Infection survey, based on an ciren between the ages of from the country: C°""ty- Sq. mile". Population. Colquitt S6S 13,636 Brooks 463 18,606 Berrien 810 19,440 Thomas 713 31,076 Ware 676 13,761 Macon 392 14.093 Muscogee 255 29,836 Worth 778 18,664 Wilkinson 431 ii,440 Washington 680 28.227 Pierce 518 8,100 Appling 775 12,336 Coffee 1,123 16,169 ?Iouston 591 22,641 examination of at least 200 chil- 6 and 18 years, taken at random Number examined. 659 316 200 257 352 267 384 432 439 632 849 433 946 209 Number infected. 578 261 183 152 296 172 192 376 404 506 742 331 784 121 Perctg. of infection. 87.0 82.0 91-5 59-1 84.9 64.4 So-o 84.0 92.0 80.0 87.0 76.4 82.6 88.0 2. Sanitary survey, based on an inspection of privy conditions at at least 100 country homes : Type of Privy. E F 600 312 331 400 202 182 2X1 24s •3S5 115 118 58 192 51 138 28 106 42 21 85 Total. 720 370 525 451 340 210 322 287 376 200 County. D Berrien 2 Colquitt Thomas 2 Ware l\Tacon Crisp Muscogee 5 Pierce Coffee Johnson II. Getting the people treated. 1. Enlisting the physicians : (i) Number of physicians in state 3,022 (2) Number of physicians personally interested 477 (3) Number of lectures to physicians 7 (4) Number of physicians thus reached 603 (5) Number of letters and circulars sent to physicians. 5,739 (6) Number of bulletins sent physicians 6,732 (7) Number of physicians now treating the disease. . . . 974 (8) Number of persons treated by physicians 6,887 2. Getting the people to seek examination and treatment : (i) Number of schools inspected (2) Number of persons examined clinically c GEORGIA. 43 (3) Number ^of persons examined microscopically 21,419 (4) Number of persons treated by field force 10,324 (5) Total number of persons treated on record 17,213 3. Work of county dispensaries : Amount of Amount County. Appropriation used. Lowndes $150.00 $99-50 Thomas 150.00 117-44 Berrien 150.00 83.32 Colquitt 150.00 82.51 Brooks 150.00 60.32 Ware 150.00 69.10 Macon 150.00 70.69 Pierce 150.00 127.79 Camden 100.00 79-53 Appling 150.00 146 10 Coffee 150.00 137.26 Washington 150.00 104.02 Worth 150.00 147.79 Muscogee 150.00 140.73 Crisp 150.00 103.60 Wilkinson 150.00 81.13 Houston 150.00 146.31 Turner 150.00 8844 Charlton 75-00 ) Clinch 75.00 ) Burke 150.00 -Jefferson 150.00 Duration of campaign. 6 weeks 7 weeks 7 weeks 6 weeks 6 weeks weeks weeks weeks weeks weeks 6 weeks 7 weeks weeks weeks weeks week? weeks weeks In operation Not open Not open Number of persons and times treated. County. 123456 Lowndes 122 42 20 o Thomas 686 118 17 5 Berrien 819 81 16 i Colquitt 650 93 17 7 Ware 429 126 12 Brooks 515 52 4 Macon 239 44 23 2 Washington . . 832 168 22 i 163 Wilkinson 653 114 25 4 3 48 Worth 762 76 2 Crisp 215 821 Pierce 1,114 307 iS i i Muscogee 307 81 23 8 3 Turner 347 52 6 1 Houston 211 10 1 Camden 401 105 16 Coffee 1,154 187 41 2 Totals .-.9456 1.664 262 33 7 211 Total Total people treat- treated, ments 122 686 819 650 429 S15 239 832 653 762 215 1,114 307 347 211 401 1,154 184 8,216 917 767 567 571 308 1,186 847 840 226 1.438 422 406 222 coo 1.384 9,456 11,633 44 GEORGIA. 4. Laboratory Report: ( 1 ) Specimens examined 2,985 (2) Specimens positive , . 1,559 5. Summary : (1) Number of persons examined 21,419 (2) Number of persons treated by physicians .' 6,887 (3) Number of persons treated by staff 10,324 (4) Total number of persons treated 17,211 III. Educating the people in sanitation. 1. By public lectures: (i) Number of public lectures delivered 334 (2) Number of persons thus reached (Estimated) . . . .29,022 2. Through the- schools: (i) Number of teachers in state 8,714 (2) Number of teachers reached by visit 17 (3) Number of teachers reached by bulletin (4) Number of teachers reached at institutes 1,165 (5) Number of teachers reached by letter 423 3. By bulletins, leaflets and special literature : (i) Number of bulletins, leaflets, etc 143,258 4. Through the public press : (i) Number of papers in state 311 (2) Number of papers personally visited 57 (3) Number of letters to press (4) Number of articles furnished for publication 55 IV. Notes on work of the year. 1. The bill providing for county or district health officers and medical inspection of school children, while not receiv- ing a constitutional majority, did receive a majority vote in the legislature of this year and helped to create public sentiment which will ultimately result in the enactment of this measure. 2. The boards of education in the following counties have passed resolutions adopting sanitary surface privies : Coffee, Camden, Charlton, Tift, Pierce and Ware. 3. As a result of our work in connection with women's clubs and other educational agencies, the attitude of the public toward all public health matters has been changed favorably ; our chartces for necessary legislation have been greatly enhanced. KENTUCKY. 45 KENTUCKY. I. State survey by counties. 1. Infection survey, based on an examination of at least 500 per- sons, taken at random : Tnuntv Area in p„„,,i^f|„„ Xuniber Number Perctg. of County. Sq. miles. Population. examined, infected, infection. Bell 369 28,447 6,474 2,039 315 Breathitt 4S0 i7.540 i,797 1,288 71.7 Butler 409 15,805 1,454 172 11.8 Clark 267 17,987 1,491 128 08.6 Edmonson... 260 10,469 2,723 1,541 36.6 Hickman 224 11,756 699 10 01.4 Jefferson 371 262,920 2,045 33 01.6 Knox 352 22,116 5,279 2,085 39.S Leslie 397 8,976 590 277 46.9 Whitley 578 31,982 949 250 26.3 State institutions 1.437 1,437 198 13.8 2. Sanitary survey, based on an inspection of privy conditions at at least 100 country homes : Number of Privy Types. County. A B C D E F Total. Bell 7 251 sn 769 Breathitt 2 17 206 225 Butler 71 S3 409 533 Clark 41 27 273 341 Edmonson 58 560 618 Hickman 67 82 124 273 Jefferson I 3 5 126 189 232 556 Knox 2 I 41 117 138 299 Warren 2 3 67 112 188 372 II. Getting the people treated. 1. Enlisting the physicians : (i) Number of physicians in state 3,7o8 (2) Number of physicians personally visited 2,358 (3) Number of lectures to physicians 6b (4) Number of physicians thus reached 1,854 (5) Number of letters and circulars to physicians 16,405 (6) Number of physicians now treating the disease. . . . 1,125 (7) Number of persons treated by physicians 15.750 2. Getting the people to seek examination and treatment : (i) Number of schools inspected 220 (2) Number of persons examined : Clinically Micros'copically 22,831 46 KENTUCKY. (3) Number of persons treated by field force 7,080 (4) Number treated in State Institutions 198 (5) Total number persons treated on record 23,028 3. Work of county -dispensaries: Doctor and Amt. of county. Co. appro. (Dr. Lock.) Bell $200.00 Knox 15000 (Dr. Richmond.) Edmonson .... 200.00 Jefferson 750.00 (Dr. Shirley.) Breathitt 150.00 (Dr. Steele.) Butler 25000 ilxpendi- tures. Duration of campaign. Microscopic Pos. Neg. Total $200.00 150.00 5 weeks 6 weeks 1,213 1,165 2,006 2,06s 3219 3,230 250.00 750.00 5 weeks 5 weeks 1,477 2,Z7 1,257 1,418 2,734 1. 755 150.00 5 weeks 1,283 526 1,809 250.00 5 weeks Totals . $1,700.00 $1,750.00 31 weeks 176 5,651 1,126 8,398 1,302 14,049 Number of persons and times treated : Doctor and i 2 county. (Dr. Lock.) Bell 1,340 26 Knox 1,926 29 (Dr. Richmond.) Edmonson 1,292 I Jefferson 330 (Dr. Shirley.) Breathitt Total No. treated. 1,340 1,926 1,29 (Dr. Steele.) Butler 167 Totals 6,353 4- 13 13 82 1,292 330 1,298 167 6,353 Total No. treatments. 1,366 1,955 1,293 330 1,311 180 6,435 Report of laboratory: (i) Total number of specimens examined 31,006 (2) Number specimens sent in by physicians 21,962 (3) Number sent in by dispensaries 2,693 (4) Number sent in by individuals 461 (5) Number containing hookworm ova 10,356 (6) Number negative to hookworm '. . . .20,635 Note. — 997 Specimens from Knox County sent to laboratory for ex- aminations. KENTUCKY. 47 (7) Number specimens negative to parasites 15,643 (8) Number of specimens containing Ascaris Lumbric. 7255 (9) Number of specimens containing Trichiuria Tri- chiuris 2,546 (10) Number containing Hymenolepis Nana 626 (11) Number of mailing cases distributed 30,382 (12) Number of mailing cases returned 15,282 5. Summary : (1) Number of persons examined: At the laboratory 31,006 At the dispensaries 14,049 (2) Number treated : By physicians i5,75o By staff 7,080 In State Institutions 198 III. Educating the people in sanitation. 1. By public lectures: (i) Number of public lectures delivered 480 (2) Estimated number persons thus reached 80,122 2. Through the schools : (i) Number of teachers in state 9,487 (2) Number of teachers reached by visit 1,635 (3) Number of teachers reached by letter 6,750 (4) Number of teachers reached by bulletin (5) Number teachers reached at institutes 4,250 3. By bulletins, leaflets and special literature : (i) Total number of bulletins and leaflets distributed. 179,130 4. Through the press : (i) Number of papers in the state 1,640 (2) Number of papers personally visited 70 (3) Number of letters to press 1,650 (4) Number of articles furnished for publication 1,943 IV. Notes on work of the year. 1. This is Kentucky's first year in the work. We are grateful to workers in the other states for many plans of procedure which had already been perfected for our use. 2. The Kentucky sanitary privy has become practicable. We offer definite plans for a septic tank for schools and country homes ; it can be built at small cost ; it is water- tight, fly-proof, devoid of bad odors and sanitary 48 KENTUCKY. 3. Repeated tests by re-examination and a careful check system have shown that the method of microscopic exami- nation devised by our State force is more rapid and more accurate than examination without the centrifuge. 4. In no other respect has this work been of more value than in bringing to the attention of physicians the growing importance of accurate methods of diagnosis. During the year physicians of the state treated 15,750 cases of hook- worm disease; of these 15,075, or 96%, were diagnosed microscopically. During the year these physicians treated 17,471 cases of tuberculosis; of these only 5,265 were con- firmed microscopically. They treated 19,125 cases of gonorrhea; of these only 3,127 had been diagnosed micro- scopically. They treated 12,375 cases of diphtheria; of these only 1,350 had been confirmed microscopically. The state laboratory is at the service of the physicians of the state; it is confidently believed that during 1913 a much larger percentage of laboratory examinations in other dis- eases will be made. 5. In a remarkable degree we have had the co-operation of every agency working for good in Kentucky: (a) The officers and members of the State Board of Health have given us a kind of support without which our work would have been impossible^ One day of the annual school for county health officers was devoted to our work ; the instruction there given reached all of the 120 counties in the state ; our state bacteriologist has personally supervised the training of our 10 microscopists ; she has held herself personally responsible for the accuracy of their work; a portion of each of her public addresses is devoted to this work; she secured the county ap- propriation in one of our dispensary counties. The vital KENTUCKY. 49 statistics organization, with a lay representative in practically every school district in the state, has been of incalculable service in our work. Dr. Heizer, the registrar of vital statis- • tics, personally visited the local registrars in each dispensary county in the early part of the work so as to secure their live interest in it. He has emphasized in all his public addresses the economic loss from hookworm morbidity as altogether out of proportion to the apparent death rate from the disease. The Secretary of the State Board of Health has been present in person during a part of each of our dispensary campaigns ; he has used the results of the work as a basis for the program for the future health work in the state. The president and members of the board have each visited some of the county dispensaries and have given an amount of moral support to the work without which it could not have been successful. (&) Of even greater importance has been the co-operation of the Kentucky State Medical Association, with its 114 county medical societies and the medical profession of the state. In the six counties worked the physicians have, contributed 492 days to this service without compensation. When it is under- stood that less than 25 cases of hookworm disease had been treated in Kentucky prior to January i, 191 1, nothing better shows the spirit of our doctors than that 1,125 of them have gone on record as treating 15,750 cases in their private prac- tice in the past twelve months. The Kentucky State Medical Association pays the salary of one microscopist ; this young woman acts as reporter for the Kentucky Medical Journal, so that all physicians in the state are kept informed as to the progress of the work. (c) Our county health officers, the medical superintendents of our state eleemosynary institutions and physicians in charge 50 KENTUCKY. of mining and other industrial plants have rendered special service. The county health officer has been present at no less than one-half of the dispensary appointments, and in Jefferson and Knox counties at all of them. If charged for at the ordi- nary per diem rate the annual salaries of neither of these men would pay for their services during the dispensary alone. To give but a few concrete examples of such service, Dr. W. E. Ray, the health officer of Leslie county, attended the annual school for county health officers in Louisville ; recognized from the addresses on hookworm disease that his people were in- fected with it ; returned home and secured authority from his fiscal court to purchase a stereopticon ; with slides furnished by us he lectured all over his county and, with the co-operation of Dr. Collins, his only colleague, sent in 590 specimens from the most prominent people of the county, of which one-half were found infected. He got Dr. Heizer to deliver an address before the county teachers' institute to an audi- ence representing practically the entire county. The fiscal court, in direct response to Dr. Ray's campaign, appropriated $300 for the dispensary. In the same spirit Doctors Menifee, of Grant, and Piper, of -Logan counties, and many others, have secured stereopticons and are making telling inroads on the preventable diseases in their counties. (d) The co-operation of county officials has been prompt and aggressive. We have found that it is only necessary to explain our work in plain English to the county judges and magistrates to secure adequate appropriations of money and to secure their moral support and personal co-operation in these campaigns. As an example, Judge Stampler, of the Bell County Court, attended the annual school for county health officers: became enthused by it; returned home and set his KENTUCKY. 5 1 people on fire with a desire to secure the benefits of heaUh. He preached sermons in the churches ; taught lessons in schools to pupils, teachers and p^arents; explained the purposes of the campaign to groups of men working on the public roads ; went out into the hustings with the cry for more and better life on his lips and made of the dispensary campaign in Knox county a success in better health for his people in such way as to entitle him to their confidence and enduring esteem. In Breathitt county J. W. Hagans, the County Judge, or W. H. Blanton, the County Attorney, or both, accompanied Dr. Shir- ley and his microscopists on horse-back or on a hand-car to every one of their appointments. One of these men made ad- dresses each time Dr. Shirley did, and with equal or greater eflfect, because they were talking to their own people, who knew them and loved them. In Edmonson county John A. Logan, the County Attorney, personally guaranteed the appro- priation for the dispensary work; built the first sanitary privy in the county at his own house ; submitted specimens for ex- amination from every member of his family and co-operated in such way as to secure the examination of one-third of the entire population of the county. Squire Durbin gave a barbecue on the first dispensary day and led his neighbors and life-tiine friends in the movement for better health conditions. At Bee Springs, in this county, Michael Vincent, State Senator ; H. T. Rich, ex-Representative, and J. C. Van Meter, the local regis- trar of vital statistics, as committee on arrangements devoted days in preparing for the dispensary at that point and made this the largest dispensary we have ever held in a purely rural community. In Bell and Butler counties the magistrates and physicians co-operated in the same way. At several dispensaries practi- 52 KENTUCKY. cally every physician in the county was present and helped in the work. Jefferson county, the richest and most populous county in the State, has taken up the work with the determination to push it until intestinal parasites have been eradicated. The work will be conducted systematically by districts and will require months for its completion. The fiscal court has voted $600, and has promised to finance the work until the job is done. The co-operation of the fiscal court, of the county board of health, of the full time county health officer, with his laboratory, with his bacteriologist and his sanitary inspec- tors, of the county board of education, of the teachers, of the commercial bodies .of Louisville and the citizenship of the county give promise of making this campaign historic. (e) The State Press Association has been at our service; it has carried life saving information daily and weekly to every newspaper reading faniily in Kentucky. (/) We have had the hearty co-operation of the State Su- perintendent of Education, county school superintendents and public school teachers. One teacher in Leslie county, 40 miles from a railroad and 20 miles from his county seat, sent to the state laboratory specimens from his 25 pupils ; 24 of them were found infected. Being miles from a physician he treated tbese 24 pupils himself, and, in his, own words, "made live pupils out of dead ones." More than 20 country schools in the state have had a specimen from every pupil examined ; more than 500 have had a majority of their pupils examined ; more than 1,000 soil pollution cliarts of the United State". Public Health Service have been distributed among country school teachers ; many of the schools use the bulletin of the State Board of Health as a text book. Next year the State KENTUCKY. 53 Department of Education at its own expense will place in the hands of every public school child a text book on hygiene, written by our state registrar of vital statistics. This book will contain a chapter on hookworm disease, another chapter on the sanitary privy, and will be profusely illustrated with pictures. (g) We have had the active co-operation of the State Fed- eration of Women's Clubs, an organization which guides the public activities of the women of Kentucky. Our state bacteriologist is an oflScer of the state organization and every assistant in her laboratory is a member. One-half of the attendance at our dispensaries at Barbourville, Corbin, Pine- ville, Middlesboro, Jackson, Morgantown and the towns in Jefferson county has been secured through the activity of the organized women's clubs. These women have been active in sending in specimens from their own families and securing the examination and treatment of their neighbors. Fifty women, the wives or daughters of the most prominent men in the state, were present at the meeting of our State Medical Association to hear the address delivered by the chairman of their health committee. They came as an earnest of their real desire to be of practical assistance in this co-operative campaign. 54 LOUISIANA. LOUISIANA. I. State survey by counties. 1. Infection survey, based on an examination of at least 200 chil- dren between the ages of 6 and 18 years, taken at random from the country: •t)„ ■ . Area in r)„„„i.,..- „ Number Number Perctg. of ^^"'^- Sq. miles. P°P"lation. examined, infected, infection. Claiborne 764 23,029 203 66 32.0 Livingston 626 8,100 1,270 725 57.0 Morehouse 809 16,634 252 48 ig.o Rapides 1,370 39,578 397 124 31.2 St. Helena - 409 8,479 1,461 750 51.3 St. Landry 1,662 52,906 475 30 6.3 Tangipahoa.... 777 17,625 1,250 616 49.2 Vernon 1,321 10,327 2,038 1,351 66.2 Webster 682 15 125 549 iS3 27-8 Winn 957 9,648 341 177 48.0 2. Sanitary survey, based on an inspection of privy conditions at at least 100 country homes : Type of Privy. Parish. A B C D E F Total. Claiborne 2 2 g 15 213 375 616 Livingston 52 241 163 456 Morehouse 6 28 408 187 629 Rapides 4 224 260 488 St. Helena 9 191 150 350 St. Landry. 22 21 52 1,665 459 2,219 Tangipahoa 2 20 18 112 266 30 448 Vernon 103 6 1,270 349 1,728 Webster 309 328 637 Winn 2 2 79 346 429 II. Getting the people treated. I. Enlisting the physicians : (i) NumtTer of physicians in state 2,033 (2) Number of physicians personally interviewed 377 (3) Number of lectures to physicians 3 (4) Number of physicians thus reached 100 (5) Number circular letters sent to physicians 11,863 (6) Number of bulletins sent to physicians 660 (7) Number of physicians now treating the disease... 161 (8) Number of persons treated by physicians 5,342 LOUISIANA. Getting the people to seek examination and treatment: (i) Number of schools inspected 298 (2) Number of persons examined : Clinically 36,769 Microscopically 8,877 (3) Total number of persons examined 45,646 (4) Number of persons treated by field force I7,S43 (5) Total number of persons treated on record 22,885 3. Work of county dispensaries : Doctor and Amount of Parish. appro. (Dr. Wright.) Claiborne $150.00 Morehouse 200.00 Webster 150.00 Ouachita* 200.00 $700.00 Expendi- tures. $150.00 200.00 150.00 $500.00 Duration of campaign. 6 weeks 6 weeks 6 weeks 18 weeks (Dr. Adams.) Feliciana* 100.00 Livingston 100.00 St. Helena 100 00 Tangipahoa 100.00 $400.00 100.00 100.00 100.00 $300.00 6 weeks 6 weeks 7 weeks 19 weeks (Dr. Baucum.) La Salle* 150.00 Rapides 150.00 150.00 7 weeks Winn 183.00 18300 6 weeks $483.00 $333-00 13 weeks (Dr. Azar.) Vernon 330.00 330.00 6 weeks Grand totals $1,913.00 $1,463.00 56 weeks (Dr. Wright.) Claiborne 1,113 7I2 19S 6 1,113 2,026 Morehouse 425 71 12 425 508 Webster 631 513 150 11 i 631 1.306 2,169 1,296 357 17 1 2,169 3840 *Dispensary work just be^un. 56 LOUISIANA. Doctor and Number of persons and times treated. Total No. Total No. Parish 12 3 4 5 treated treatm'ts (Dr Adams.) Livingston 985 565 196 n pSs l,7S7 St. Helena 766 512 251 21 766 1,550 Tangipahoa 1,226 670 327 4 4 1,226 2,231 2,977 1,747 774 36 4 2,977 5,538 (Dr. Baucum.) Rapides Winn 1,207 2,283 713 910 133 21 7 2 1,207 2,283 2,076 ^.277 3,490 1,623 210 28 2 3,490 5,353 (Dr. Azar.) Vernon 2,384 1,347 669 53 2 2,384 4,455 Grand totals . . 11,020 6,013 2,010 134 9 11,020 19.186 ( 1 ) Number of specimens examined 659 (2) Nmnber of specimens positive, hookworm 126 (3) Percentage of infection thus shown ig.i S. Suinmary : (i) .Number persons examined 45,646 (2) Number treated by : Physicians , .• 5,342 Staff 17,543 (3) Total number treated 22,885 III. Educating the people in sanitation. 1. By public lectures: (i) Number of public lectures delivered 407 (2) Estimated number of persons thus reached 33 999 2. Through the schools : (i) Number of teachers in state 6.403 (2) Number of teachers reached by visit 894 (3) Number of teachers reached by letter 1.200 (4) Number of teachers reached by bulletins 4,000 (5) Number of teachers reached at institutes 1,360 3. By bulletins, leaflets and special literature : (i) Number of bulletins distributed 62,265 4. By the public press; (i) Number of papers in state 198 (2) Number of papers personally visited ■ 60 (3) Number of letters to press 572 (4) Number of articles furnished for publication 51 LOUISIANA. 57 IV. Notes on work of the year. 1. The State legislature enacted the following: (a) House Bill No. 268. AN ACT to further carry into effect Articles 296 and 297 of the Constitution of the State of Louisiana and to preserve the public health; to authorize the State Board of Health to revise the Sanitary Code, etc. Section 3 of the above Act prescribes that fines shall be im- posed for violation of any regulation contained in the Sanitary Code. Section 4 prescribes that said fines shall be paid into the treasury of the. state to the credit of the State Board of Health. -The appropriation for the State Board of Health was in- creased from $25,000 to $40,000 per annum. (b) ACT No. 173 confers the same rights upon municipal and parish boards of health, with the following proviso : "They shall act'tmder the supervision and advice of the State Board of Health and pass no ordinance in conflict or inconsist- ent with the powers and duties of the State Board of Health, but shall in all health and sanitary measures which they may adopt be auxiliary to and act in harmony with the State Board of Health, and shall make such reports monthly to said Board of Health and furnish such other information as the State Board may require." (c) ACT No. 131. Exempting Board of Health from pay- ing costs of court. ACT No. 161. Establishing State Tuberculosis Commis- sion and prescribing that the President and Secretary of the State Board of Health shall be members of said Commission, etc. 2. During the year the State Board of Health has promul- gated regulations providing for : 58 LOUISIANA. (a) Abolishing common drinking cup and roller towel. (b) Election of State Registrar of Vital Statistics. (c) Local food, drug and sanitary inspectors without com- pensation. (d) Anti-diphtheretic serum in the interest of the poor. (e) A State Sanitary engineer. 3. The following parishes passed regulations providing for sanitary privies : Avoyelles, Bienville, Calcasieu, Caldwell, Ouachita, St. Bernard, St. Helena, St. Tammany, Tangipahoa. Number of sanitary privies built, 825. 4. Morehouse Parish increased the salary .of the parish health officer $750 per annum, and prescribed that an inspec- tion of all schools should be made semi-annually. Livingston Parish health officer devoting his full time to public health work. MISSISSIPPI. 59 MISSISSIPPI. I. State survey by counties. 1. Infection survey, based on an examination of at least 200 cliil- dren between the ages of 6 and 18 years, taken at random from the country: ronntv Area in pn„,,ut\^„ Number Number Perctg. of Lounty. 5q ^^^^^ Population. e^a,„ined infected, infection. Perry 1,091 14,682 767 610 70.0 Hancock 611 11,886 710 504 70.0 Lincoln 574 21,552 1,159 824 71.0 Covington 577 13,076 1,041 830 79.0 Forrest 906 740 81.0 Simpson 578 12,800 1,375 1,021 74.0 Smith 610 13,055 150 141 94.0 Union 418 16,52? 959 490 51.0 Chickasaw 507 I9,8g2 112 26 230 Alcorn 402 14,987 255 218 85.0 Tippah 456 13,983 497 294 59.0 Lafayette 673 22,110 134 35 26.0 Amite 708 20,708 1,147 856 74.0 Pike 697 27,545 1,099 672 61.0 Wilkinson 664. 21,453 476 345 72.0 Copiah 748 34395 1,041 493 47-0 Winston 577 14,124 374 3^9 85.0 Clarke 664 17,741 244 221 90.0 Leake 561 17,360 769 563 73-0 Lauderdale 677 38,150 284 210 73.0 Franklin 555 18678 1,655 1,267 76.0 Jackson 1,073 16,513 960 855 89.0 Greene 819 6,795 1,349 1,158 850 Jasper 647 i5,394 i,i70 920 78.0 Wayne 788 12,539 1,578 1,418 89.0 Kemper 704 20,492 336 255 75.0 2. ■ Sanitary survey, based on an inspection of privy conditions at at least 100 country homes : Type oi- Privy. County. B C D E. F Total. Perry 12 192 204 Hancock S3 373 426 Union 26 106 132 Chickasaw 106 123 229 6o MISSISSIPPI. Alcorn Marshall Lafayette Tippah Lincoln Covington Forrest Simpson Smith Amite Pike Wilkinson Copiah Franklin Jackson Jefferson 15 Greene Winston Clarke i Leake Lauderdale Jasper Wayne Kemper II. Getting the people treated. 1. Enlisting the physicians : ' (i) Number of physicians in state 1.783 (2) Xumber of physicians personally interviewed.;... 90S (3) Xumber of lectures to physicians 16 (4) Xumber of physicians thus reached 643 (5) Xumber of circular letters sent to phVsicians 8,794 (6) Number of bulletins sent to physicians 16,456 (7) Number of physicians now treating the disease. . . . 1,296 (8) X^uniber of persons treated by physicians 10 201 2, Getting the people to seek examination and treatment : (i) Number of schools inspected 699 (2) Number of families examined 11. 104 (3) Number of persons examined : Clinically 11.214 Microscopically 39.26^ (4) Number of persons treated by field force 33.977 81 13 94* 6s 200 265 26 399 42s 36 180 21 38 59' 64 246 310 93 143 2.^6 29 297 326 2 190 192 289 31S 604 S04 55 559 340 27 367 345 345 20 384 786 1,190 35 S12 833 1,380 15 158 152 310 8 236 651 895 158 151 309 I 159 123 284 170 284 454 235 234 469 92 2b5 3S7 143 323 466 1i 109 242 *Survey not completed. MISSISSIPPI. 6i '^ QQ "^ 1"! t^ 'Sf 00 ^ CO t^ "^ «^ 0\ M o fr> in ■^ tN. 1^ 01 "-I 00 lo 'O m M 01 CM m ■^ T^ hh" hT D o Pi o o .H^ w O ^ OO " CO l-H CO 00 (N r^ tN vo 00 vo o 1^ CO fO C'J 3 ° O 1-1 ■O CO ^v8 o V) yi in m (rt trt tf) Ul en CO tn tft en Ul Ol tn d ^ ^ ^ ^ ^ j!i ^ ^ ^^ ^ ^ ^ ^ ^ ^ ^ bp . ^O o -t 1-1 w „ 00 01 o o ro -t 00 t-^ o rt u W •"^ ^ l-l " T3 8 1^ 00 o\ ro 8 00 o in oo 8 CO 8 *i QJ -^ w ci (N -t 6 K. 9 ;^ d CO d « ro \0 1^ CO U 62 MISSISSIPPI. "a B Q N ■* o\ a\ n o\ "_ xn m" of O o r^ lo Tf »n o o ! O ^ o\ ^ -^ 0\ " "^ w li-) \0 rO "^ O 0\ t^ f^ m 0\ f^ 'S « ^ t -s (U -H C^ •a Q tn' tn wi ^ ^ ^, dj at u * to ^a ^t 8 1 8 o q 88 d o 01 i o o 8 S o -" g t--* 00 Lo m In. Tf iM o m (m" t-T oT r^vo CO 1 vo ir^ U-) o\ m Tf -:!-M3 t^ 00 rn W -^ CD •^ ■* t^ I \o =^ 3 CI^ CM 10 vfi^ to oT H-T IN w l-t w kh" -^ t-T i-i o< 00 ^ I r^ ^ 'a- I ,g 0\ pq in 1 MD o 3 oU Q o 00.0 <: H D 9 H 3 pq Q .t; ^ . < ^ Oi u J2 Q .0 O o m « S H 64 MISSISSIPPI. o ■ o in Ov w 00 KO \n p^ n\ oo y^ in •-< o op o t^ r^ Tj- Q 00 •* n \o oo c^ f^ fo ro to <^ ro ^•o ■^ QJ ro l~x u-) ro Cu rt Tj- t^ 00 o -*-' qj in I-- i^ l^ O u hh" of i-T H-^ iz ^^ a. o 00 0\ "^- * PD IN. O M 0\ O \o fO "* O rn VO 00 M N m 00 \!? CN^ N o_ o_ VO M M 1-1 *f 1-1 ID o ^ 00 l-N PO r^ M W H* ffi O 3 Q ^ U hJ o rt t; s 5 1) <3 (u Ph ffi O en ^ O H bo tn c o o o .5 E U ^!^ W W o H MISSISSIPPI. 65 4. Laboratory Report: (1) Total number of specimens examined 1,273 (2) Number containing' hookworm ova 1,247 (3) Number containing other parasites 26 5. Summary : (i) Number of persons examined 50,507 (2) Number of persons treated by physicians I0,20i (3) Number of persons treated by staff 33,977 (4) Total number persons treated 44,178 III. Educating the people in sanitation. 1. By public lectures : (i) Number of public lectures delivered 1,034 (2) Estimated number of -persons reached 97,795 2. Through the schools : (i) Number of teachers in state 10,166 (2) Number of teachers reached by visit 731 (3) Number of teachers reached by letter 1,273 (4) Number of teachers reached by bulletin all (5) Number of teachers reached at institutes 977 3. By bulletins, leaflets and special literature : (i) Total number of bulletins and leaflets distributed. 224,997 4. Through the press : (i) Number of papers in state 234 (2) Number of papers personally visited 172 (3) Number of letters to press 1,306 (4) Number of articles furnished for publication.... 1,055 IV. Notes on work of the year 1. The 1912 legislature enacted: (a) A law requiring the M. D. degree from a reputable medical college before being admitted to the licensing exami- nation for the practice of medicine. (b) A law requiring the reporting of births and deaths of the entire state. (c) A law increasing the appropriation from $8,000 to $22,500 per annum. 2. The State Board of Health has promulgated a sanitary code regulating the sanitary conditions of hotels, restaurants, 66 MISSISSIPPI. meat markets, dairies, depots, trains and other places of public utility, and also relative to vital statistics. 3, The following towns have passed ordinances requiring sanitary closets : Blue Mountain, Morton and Collins. During the year 727 sanitary privies have been built. 4. The work of the present year has shown a decided gain as compared with that of last year. The entire scope of the work of the State Board of Health has been enlarged, which is evidenced by the fact that when the campaign was started for the eradication of hookworm disease in June, 1910, the quarters of the State Board of Health consisted of two rooms, and there was but little equipment with which to work. There was no State Board of Health laboratory, and the Bureau of Vital Statistics had not been created by legislative enactment. Very little attention had been given to municipal inspection, and the improvement of the sanitation of towns and cities throughout the state. The citizenship of the state, in large measure, had given but little consideration to questions of public health of state-wide importance. The organization of the health interests of the state was practically untouched and the various agencies that can be used for the advancement of a higher order of civilization by the improvement of the sanitary environment of the people of the state had not been enlisted in this important and far-reaching movement. There has come a change in the affairs of the state, and today the quarters of the State Board of Health consist of the entire floor of one of the main office buildings of Jackson. There is a splendidly equipped laboratory, which is well manned, and during its second year of existence 4,491 speci- mens of typhoid fever, tuberculosis, malaria, hookworm and other diseases have been examined. The Bureau of Vital Sta- MISSISSIPPI. 67 tistics has been organized upon a most efficient basis and is in charge of a well trained statistician who is securing results. The position of Chief Sanitary Inspector has been created, the purpose of which is to. have a competent physician and sanitarian inspect systematically all towns and cities of the state of 500 inhabitants and over. This position was filled on June 1st, and since that time an aggressive and most effective campaign has been waged for improving municipal sanitation. It is the subject of general comment that marked results have been achieved and much improvement effected in the sanita- tion of hotels, restaurants, meat markets, slaughter-houses, dairies, depots, railroad coaches and other places of public utility. There is perhaps no Southern state doing this work more systematically than is being done in Mississippi. 5. The standard of the medical profession has also been elevated by the enactment of a law requiring every student of medicine to have a medical degree from a reputable medical college before being allowed to practice. The State Board of Health is also vigilant and thoroughly imbued with the idea of protecting the, standard of the medical profession. 6. In general the health interests of the state have been thoroughly organized, and today there is perhaps no com- munity or portion of the state that has not been awakened to the importance of a higher type of citizenship as a result of an improved sanitary environment. The various agencies of the state have been enlisted as never before in a state-wide cam- paign for the betterment of the health conditions of all the people, and, as a consequence, results have been accomplished. 68 NORTH CAROLINA. NORTH CAROLINA. I. State survey by counties. I. Infection survey, based on an examination of at least 200 chil- dren between the ages of 6 and 18 years, taken at random from the country: ^ . Area in -r. .., , • Number Number Per'ctg. of Co'i^ty- Sq. miles. Population. ^^^^^^^^ i„f,^t,d_ infection. Anson 461 25,465 i,34S 427 3^ Beaufort 819 30,887 423 280 66 Bertie 618 23,039 1,539 743 48 Bladen 900 18,006 257 131 50 Buncombe 520 49,798 1,103 257 23 Carteret 520 13,776 1,333 860 S4 Catawba 440 27,918 1,119 5i4 45 Chowan 240 11,303 544 220 40 Cleveland 420 29,494 2,532' 1,036 40 Craven 900 25,594 i,509 828 54 Edgecombe 515 32,010 1,149 421 38 Franklin 420 24,692 855 296 34 Gaston 346 37,063 2,763 1,130 41 Gates 360 10,455 889 318 35 Greene 300 13,083 544 270 49 Harnett 840 22,174 763 362 47 Henderson 366 16,262 811 481 58 Iredell 650 34,315 1,976 537 27 Jones. 450 8,721 791 452 57 Lee 360 11,376 742 520 70 Lenoir.\ 633 315 48 Lincoln 300 17,132 2,209 853 39 Martin 500 i7,797 457 227 47 Nash 520 43,727 1,448 731 50 New Hanover 199 32,037 268 147 51 Richmond 472 19.673 1,600 650 40 Rutherford 470 28,385 1,215 622 51 Scotland 387 15,363 195 74 38 Stokes 500 -20,151 1,222 946 -78 Surry 600 29,709 1,699 1,002 59 Wilkes 700 30,282 1,429 1,121 ■^y Wilson 24,269 1,576 876 55 Yadkin 320 15,428 1,443 1,098 76 NORTH CAROLINA. 69 2. Sanitary survey, based on an inspection of privy conditions at at least 100 country homes : Number of Privy Types. County. D E F Total Anson 141 94 235 Beaufort 222 341 563 Bertie 283 172 455 Carteret 88 62 150 Chowan 2 117 137 256 Craven 159 204 363 Franklin 71 95 166 Gates 216 195 ■ 411 Henderson , 52 67 119 Lee 160 97 257 Martin 257 247 504 Nash 113 74 187 203 80 • 154 102 357 184 Richmond . .... 2 Scotland - 195 199 394 Stokes 88 339 427 Surry 124 485 609 Watauga. .'. 39 120 159 Wilkes 2 T/|/| 267 460 299 Yadkin 32 II. Getting the people treated. 1. Enlisting the physicians : (1) Number of physicians in state 1,720 (2) Number of physicians personally visited 1,145 (3) Number of lectures to physicians 10 (4) Number of physicians thus reached 168 (5) Number of circular letters sent to physicians..'.. 8,622 (6) Number of prescription pads sent to physicians .... 330 (7) Number of physicians treating the disease 1-307 (8) Number of persons treated by physicians 15.859 2. Getting the people to seek examination and treatment : (i) Number of schools inspected 197 (2) Number of persons examined : Clinically 1,978 Microscopically 135,867 137.845 (3) Number of persons treated by field force 42,132 70 o H NORTH CAROLINA. r^ ro\0 00 q f^ -^ O oT ^ n" t< in in po m' t-t \o coo 00 r^ r^ vO VO Of Tf m 0\ e^.-s-^, ;5> ^.b ;h^ ui i^ — — ~ Xt^oo inoo ■* ^ ^ of CO 'P-, t^ in^ vo ONVO o 00 01 O O COOO O\00 o\ 01* i-T -^ h" of m" CO -f QQ rt 5-.00 CO 0\ 3& 0\ CO o ►1 M "^ in o\ I-* 00 o c o M i5 C3 O u. < 3 Q K w s < tn X V W CO o\>o -^vo *o ■* ■* ? o !?!^8 8 8S'^§8 c V a. o o m food oi d "Sod cfiod 01 wNO^coiNOli-ii-. W & ^ ■4 CO en en c/} CA en en ^^^^^^^ > PM c si tJ u-ffi Q o " ^^ j: Q c 2; ■ .t3 M o H (/} Q c J: ■4-» O o 0_ UJ to ■* 0_' Tf w" t^\Q uS of CO NORTH CAROLINA. s ^ m o ^\0 O W O 00 of cq" (m" t< in 71 ■O M Tf CO C'l M po d\ '^ I-" tN. o On 0\ tx rt US fl4 \^ o w \O00 h- ro o PO M t-. CO 0) 00 -< N o\ moo w t^ t^ '-' o 00 fOCMN.OtN01 -^l- O 10 10 i-H^ HH^ tJ-OO 'O HH hT K-T h-T hT in CO vo ro ^00 01 O f^OO WW 0\0 0\0 ^-H o > J o ;* H r^ t^oo txoS )0 o\ o\oo 00 o "^ o 00 o\ -^ CO o t^\o in t -^00 'fOO j^ N t^ 000 fO o o M 0\ t-H fO 0\ r^ fo o\ com a M S6 3 IS m «i t/3 t/1 tfl CO tn (U dJ (U flJ (U (U U o U B o CSS g S ^ B § o cj -fe-g'J-s-a.H o ^ pqw^;uuDS< en bo S ffi* o H T3 „ C (U CS 1-1 ■ -"s-a g >-■ g S o o fc ■S P-: 72 NORTH CAROLINA. H IN. ro 00 O\00 t-OO '^ H m M 00 p6 of \o w CO moo row (N N hH "S ^2; PL, 'CM -< O >- IT) In "2 -^ 01^ c^"" in >-' 00 ^^ o'\o" 00 In '-' W ro w ^ vn Tj* o m*0 -^ o^ tN Oi CO ro ^9 O; I'N 1-^ in liSoo" ^^. ■^ t-T en en (/) w tfl en (/■; jbi ^ ^ ^ -^, ^, ^ qj (y dj oj 4> — -a ■S i g <" ^ ffif c o Id c 0\ fO 01 tN 01 xJ-VO 01 i_i *4^ 10 Tj- OVO i^ CO t^ C3\ .5 In oi tn in d ^VOOOOO in C^ *1_ tNTf ro in &. 01 -^vo CO CO p. 01 M 01 VO 01 CO iNin vo Tf «- 4«- «- kT h-l kT 00 ^ & O O O Q 0000 6 6 6 6 in "^ O in O) 01 PI (N u c a ^ 13 -u uu 000 ° ''^ ° d d\ d o t^ o fo in i-^ M 01 01 tn en c c o o £ P P Ov bo CN aj . >< ill o o (J u u O o CD c c c 3 3 3 000 E E E fe Ph o * NORTH CAROLINA. 73 J3 c E a v rt "ii 1 o 2; •a c . « >, S§ o O o o s ^ mop rrxx) o\ w po 00 t-^ 1*1 00 r^ioQN^ q_\o^ h^ q> CTi iN.^_ N i-T N w a\ -^ tN. '^ of M O 01 01 I ooi-tONwoiiNr^O LO Tj- 01 <-< N OA CO \0 01 01 C00\0 01 ■Tfinrooi rnxo 00 in ■^ m r-s of w of 1-r 0^3 01 r^ t^^ooo Oi \OOl\o^s^^*^^.fool oioo\ooo in'^iotN, 0\0m'-' O romm 00 0\ ON (O C\ f^oo t^ I^ •-. In. Tl- in lO LH l-N. f^ oi rr> -n- ■^- <~o o -1- rs-O ro t-NOO i-H \0 lO O fO IN. i-t i- Of 01 •-" m" w of of in ro f>. •«:*■ 01 rn -t IN, Tt- Tt tN. ro t- - in in 01 N 01 in ■*j- lo in IX O 01 ro in 01 lO^O \0 in ro 00 oo fo -^ in IX 01 -^ O O 01 rooo bo c o tn C O bo CM > o CI . nJ -t-. O >^23 j^ C D "J i^ (U o H c/^ t- rt I- oj P rt ^ o H 74 NORTH CAROLINA. c\f hh' of f^ fo of i-T ' vb r^ 00 POfO^W W Os'*^" \o 00 vo t^ "^00 tN. -^ hT c^ hT r^ of H o •?' 0\ M VD in c^ OnCO T* t^OOOO in 0^ On of 01 r^ro-^OvO inin 01 CO M tx -^ ,. _. o\co Tf r^ w o m CO ^00 M o\ <:^\o 0) o\ " ^ CO t^ lOVO vo 00 io\o >-i t% r^ 0\ m o U o Q O V g o .-a S & E 00 t^ Oi Q\00 00 O « Q; 00 0\ "^ CO O Ix^ ^ ^ ^00 ^00 t^ « 01 o H te w '^ ;;3 to o CO 4_, J2 -^ O fc H * NORTH CAROLINA. 75 vS •°a 3 B 1-1 t3-\0 »-" o IN. tN. 1- 01 (N ^ rt ■^ r^ ^2 '^'^ 3" o.t! c6 fO 5 inMD^ fN. -^ ro^o w lo i-Tvo' "^ i-T Tt PO H^ M M M C^ CO o rs. i-H Tj- w in 01 (N N w ^O 01 m" oT 0\ to ■* &t o . „ 00 w t^ 0*0 Q oj o^ ^00 ■^^N 00 CO fO\0 O CO W lO o of oT of fi M I i-T w H-, ^ ooo M 0) I>^ ro HH I>.00 '-' 92 2. ^s -^ -^ M o IT) g\ o\oo o, tNj "2 "^ o" CO in tF fo hT '^ o o 01 in I m in o\ CO in C3 >, O 3 S c o o «3 ^"5 CJ O u o oo 00 rr)^ rn w t-T cs li^od tC -^ i-T 8 2-c o ^ U (J Vh' u u u C QOQQQQO ^ E o H * 76 NORTH CAROLINA. Comparative Summary. Persons Treated. By physicians. By staff. Total. 1910 8,000 8,000 T911 16,709 29,172 4S,88i 1912 15,859 42,132 57,991 Totals 40,568 71,304 111,872 Microscopic Examinations. Laboratory. Co.- dispensaries. Total. 1910 7.949 7,949 1911 .■ 20,115 17,213 37,328 1912 . . . . : 9,761 126.106 135,867 Totals 37,825 143,319 181,144 NORTH CAROLINA. 77 •H !>. n -^ IN Tt Tj-O u-ivO M 'O P^ fO ON'O t^ f^ ^ , ro 0\ t^ lO Ch'O ro (^ i ' O O O PO IN >— ' o Jh 1^ en ° b« c« O u ° 2fi •S o^ g.S2 ^-^ 1- a.B^ > o c u^ t; O u o o x;-j3 j3 -tj y8 NORTH CAROLINA. III. Educating the people in sanitation. 1. By public lectures : (i) Number of public lectures delivered 454* (2) Estimated number of persons thus reached 36,849 2. Through the schools : (,i) Number of teachers reached by visit 197 (2) In the dispensary campaign the field directors have reached the teachers and other influential citizens by letters numbering more than 20,000 (3) They have also distributed handbills numbering more than 250,000 3. By bulletins, leaflets and other literature : (i) Number of bulletins distributed (hookworm dis- ease) 340 (2) Number of leaflets -distributed (hookvirorm dis- ease) 45,246 (3) Number of hookworm pamphlets distributed... 75,619 (4) Number of sanitary privy pamphlets distributed. 58,865 (5) Number of pieces of other State Board of Health literature distributed 135,000 plus 4. Through the public press : (i) Number of papers in state 310 (2) Number of papers personally visited 175 (3) Number of visits 425 (4) Number of letters to press 2300 (5) Number of articles furnished for publication. . . 319 (6) Other literature or letters : Letters to superintendents of schools 209 Letters to county commissioners 482 Letters to registers of deeds 100 IV. Notes on work of the year. I. The North Carolina campaign against hookworm disease for 1912 has progressed with gratifying results along lines similar to those pursued the latter months of 191 1. In that division of the work directed to the treatment of sufferers the people three years ago were found ignorant of the disease or apathetic toward it. They have progressed rapidly through a conversant stage and are now in the midst of a stage of ac- tivity. This means that something definite, something worth while, is being accomplished. Generally speaking, we regret *Does not include dispensary lectures. NORTH CAROUNA. 79 to say that in matters pertaining to preventing the disease by stopping soil pollution the people have not yet proceeded be- yond the conversant stage, but at the same time the progress made has been remarkable. 2. For every day of the year 1912, excepting Sundays, an average of 434 persons have been microscopically examined, making a total of 135,867 persons; and to the 42,132 of these iound infected, 96,176 treatments have been dispensed by members of our staff who, in no instance, made a charge or accepted pay from the patients. 3. Of 1,700 active physicians in the state 1,307 have sent in reports indicating that they have treated during the year 15,859 persons. Their work, added to that of the State Board of Health's staff, gives 57,991 persons treated. For 1910 the number was 8,000; for 1911 it was 45,881. To date treatment has been administered to 111,872 persons. 4. The number of microscopic examinations was, for 1910, 7.949; 191 1> 37.328; 1912, 135,867, a total to date of 181,144 examinations. 5. The number pf microscopic examinations made, rather than the number of persons treated, affords the best index as to the progress of the work, because in lightly infected areas there may be great enthusiasm and an immense amount of work done, and yet the number actually found infected may be comparatively small. In Yadkin county, for example, 34 per cent of the entire population was examined ; in Lincoln county, 32 per cent; in Wilkes, 25 per cent, and to examine one person out of every five living in a county is not unusual. In lightly infected counties greater effort is required to get the people to come to the dispensaries. 8o NORTH CAROLINA. 6. The counties appropriate $200 to $300 to pay for ad- vertising the county campaign; the cost of medicine; the tin boxes for tlie specimens, and the travehng expenses of the microscopists. Thus far 60 counties have appropriated $15,579.90, an average of $259.66 per county. In working in 54 counties $11,670.57 of county funds have been spent, an aver- age of $216.12 for each county. Nothing in excess of what was actually used was drawn out of the county treasury. Six counties are now on the waiting list to have the dispensary work; and Wilson county has made a second appropriation to have the work renewed. Commissioners in quite a number of counties have expressed a desire to have the work a second time. 7.. The growth of this feature of the work is interesting: No. of coun- Amount of Amount of ties making" county funds county funds appropria- tion. 1911 17 19 1 2 43 (for counties completed) (counties on waiting list) 60 $15,579.90 $11,670.57 8. The personnel of those who are engaged in this work is given on page 8 of this report. Two physicians and two microscopists are paid by the state; the others are paid with funds furnished by the Rockefeller Sanitary. Commission through the State Board of Health. 9. The work accomplished stands as the best evidence that every organized agency is taking a hand in the work. The press has encouraged the work in many ways, the educational made available. actually spent. -$4,300.00 $3,315-66 9,529.90 8,354-91 ) 1,750.00 NORTH CAROLINA. 8l forces have been active, and the doctors as a rule have been enthusiastic and magnanimous in their attitude. The work accredited to them in this report tells of but a small part of what they have done. The County Commissioners have listened to the appeal of the helpless and made this great free work possible. Numerous specific statements from them and from doctors who have seen the work in progress have been printed in a small pamphlet and will be gladly sent to any one on request to the State Director. 82 SOUTH CAROLINA. SOUTH CAROLINA. I. State surveys by counties. 1. Infection survey, based on an examination of at least 200 chil- dren between the ages of 6 and 18 years, taken at random from the country: Area in Number Number Perctg. of County. Sq. miles. Population, examined, infected, infection. Dillon 496 292 57 Horry 1,075 23,364 375 222 86 Marlboj-o 509 ^7,639 234 104 43 Oconee 641 23,634 256 95 38 Orangeburg.... 1,345 59,663 647 352 54 Spartanburg 762 65,560 788 245 31 2. Sanitary survey, based on an inspection of privy conditions at at least lOo country homes : Type of Privy. County. A B _C D Calhoun Chester 4 2 10 Chesterfield 3 Colleton Darlington 4 Dillon Florence Georgetown Horry i Edgefield Lancaster Laurens Marlboro 4 Oconee Orangeburg Sumter Williamsburg York II. Getting the people treated. I. Enlisting the phs'sicians : (i) Number of physicians in state I,il3 (2) Number of physicians personally interviewed 411 (3) Number of lectures to physicians 10 (4) Number of physicians thus reached 1,200 (5) Letters and circulars sent to physicians 3,200 (6) Number of bulletins sent to physicians 500 (7) Number of physicians reporting treating disease.. 624 E F Total. 98 109 207 144 $2 212 124 148 27s 89 129 218 260 223 487 181 136 317 8g ".=; 204 69 131 200 46 290 337 I.S7 iig 276 108 ISO 258 104 lOI 205 1.S6 129 289 67 138 205 141 152 293 120 80 200 89 144 233 106 117 223 SOUTH CAROLINA. 83 2. Getting the people to seek examination and treatment : ( 1 ) Number of schools inspected S3 (2) Number of persons examined clinicallj' 42,502 (3) Number of persons examined microscopically 13,872 (4) Total number of persons examined S6,374 (5) Number of persons treated at dispensaries 25,270 (6) Number of persons treated by physicians 10,840 (7) Total number of persons treated on record 36,110 3. Work of county -dispensaries ; Amount Amount County. appropriated.* used. Bamberg $50.00 $18.00 ■ Calhoun 50.00 24.75 Chester 50.00 • 30.00 Chesterfield 50.00 30.00 Colleton 50.00 59.42 Darlington 50.00 49.5° Dillon 50.00 13.50 Edgefield 50.00 15.75 Florence 50.00 56.25 Georgetown 50.00 9.90 Horry 75.00 73.95 Lee 50.00 32.00 Lexington 50.00 25.00 Marlboro 50.00 9.00 Oconee 50.00 20.00 Orangeburg 50.00 51.20 Richland 50 00 9.90 Spartanburg 50.00 30.00 Sumter 50.00 15.75 Williamsburg 50.00 27.00 *Mbney could be appropriated to defray cost of medicine only. When appropriation was exceeded, deficit was made good by county. Duration of campaign. 6 weeks 6 weeks 6 weeks 6 weeks 5'/2 weeks weeks weeks weeks weeks weeks weeks weeks weeks 6yi weeks 8 weeks ioj4 weeks 7 weeks 6 weeks 7 weeks 6 weeks 9 6 7 12 9 6 6 Doctor and county. I (Dr. Routh.) Calhoun. . . . 1,032 Colleton.... 2,081 Edgefield. . . 571 Orangeburg. 3,650 Bamberg 809 Number of persons and times treated. Total No. Total No. 271 459 82 638 386 82 360 10 344 116 6 27 I 40 19 people treated. 1,032 2,081 571 3,650 809 treat- ments. 1,391 2,929 664 4,672 1,337 Totals. . . 8,143 1,836 912 93 8,143 10,993 (Dr. Riser.) Chester 798 194 139 Lexington.. 747 506 451 Totals... 1,545 7oo 590 322 10 312 798 747 1,141 2,018 1,545 3,159 84 SOUTH CAROLINA. (Dr. Rodgers.) Chesterfield. 1,788 654 538 470 27 1,788 3,477 Darlington.. 3,711 1,050 591 65 3711 5,417 Dillon 695 136 19s 56 695 1,082 Marlboro. . . 244 45 30 6 244 325 Oconee 788 536 430 383 17 I 788 2,155 Richland 151 136 126 6 151 419 Totals... T,zn 2,557 1,910 986 44 I 7,377 12,875 (Dr. Howell.) Florence.... 2,228 702 612 22 3 2,228 3,567 Horry 2,224 1.033 697 I43 5 2,224 4,i02 Lee 1,009 679 444 191 20 I 1,009 2,434 Spartanburg. 442 400 359 288 16 442 1,505 Williamsb'g. 1,728 686 457' 59 8 3 1,728 2,941 Totals... 7.631 3,500 2,569 703 5a 4 7,631 14,549 (Dr. Weinberg.) Georgetown 118 68 38 19 118 243 Sumter 366 216 105 30 5 366 722 Totals... 484 284 143 49 5 484 965 4. Laboratory report : Specimens examined 2,090 Specimens positive 480 5. Summary : (i) Number of persons examined 56,374 (2) Number of persons treated by physicians 10 840 (3) Number of persons treated by staff 25.270 (4) Number of persons treated on record 36,110 III. Educating the people in sanitation. 1. By public lectures : (i) Number of lectures delivered 90 (2) Estimated number of persons reached by these lectures •. 5,400 2. Through the schools : (i) Number of teachers in the state 4,255 (2) Number of teachers reached by visit 50 (3) Number of teachers reached by letter 500 (4) Number of teachers reached by bulletin or leaflet. 1,000 (5) Number of teachers reached at institutes 600 3. By bulletins, leaflets and special literature : (i) Number of bulletins and leaflets distributed 100,100 4. Through the public press : (1) Number of papers in the state 156 (2) Number of papers personally visited 81 (3) Number of letters to the press 50 (4) Number of articles furnished for publication 77 SOUTH CAROLINA. 85 IV. Notes on work of the year. I. The 1912 legislature enacted the following law: "Sec. I. Be it enacted by the General Assembly of the State of South Carolina that the Executive Committee of the State Board of Health shall have the power to make, adopt, pro- mulgate and enforce reasonable rules and regulations from time to time requiring and providing for the thorough sani- tation and disinfection of all passenger cars, sleeping cars, steamboats and other vehicles of transportation in this state, and also of all convict camps, penitentiaries, hotels, schools and other places used by or open to the public ; to provide for the care, segregation and isolation of persons having, or sus- pected of having, any communicable, contagious or infectious disease; to regulate the method of disposition of garbage or sewage and any like refuse matter in or near any incorporated town, city or unincorporated town or village of the state; to provide for the thorough investigation and study of the causes of all diseases, epidemic and otherwise in this state, and the means for the prevention of contagious disease, and the pub- lication and distribution of such information as may con- tribute to the preservation of the public health and the pre- vention of disease ; to make separate orders and rules to meet any emergency not provided for by general rules and regula- tions, for the purpose of suppressing nuisances dangerous to the public health, and communicable, contagious and infec- tious diseases and other dangers to the public life and health ; Provided, however, That nothing herein contained shall be construed as in any way limiting any duty, power or powers now possessed by or heretofore granted to the said State Board of .Health or its Executive Committee by the Statutes of this state, or as affecting, modifying or repealing any rule or regulation heretofore adopted by said Board. A violation of any rule is punishable by a fine of $ioo or 30 days' imprisonment. )puhition. Number Number Pcrct examined. infected. infected, 16,688 200 131 65 10,589 200 34 10.7 22,604 200 42 jr 8,311 300 14.? 6t 16,890 243 Ill 45-6 15,039 292 143 48.9 19,163 5-^1 282 54.1 20,392 210 69 32.8 51,695 646 i6s 24.0 17,271 434 166 38.0 86 TENNESSEE. TENNESSEE. I. State survey by counties. 1. Infection survey, based on an examination of at least 200 chil- dren between the ages of 6 and 18 years, taken at ran- dom from the country : ^ , Area in *=°""'y Sq. miles. Carter 345 Johnson 290 Washington 325 Cumberland 548 Putnam 430 Jackson 325 McMinn 437 F'ranklin 610 Hamilton 427 Marion 504 2. Sanitary survey, based on an inspection of privy conditions at .'it least 100 country homes : Tvi'K OF Privy. County. C I) E F Total Carter Johnson i Washington 3 Cumberland o Putnam J ackson o McMinn o Franklin o ]■ lamillon o Marion II. Getting the people treated. 1. Enlisting the physicians : (i) Number of physicians in state 3,449 (2) Number of physicians personally visited , 940 (3) Number of lectures to physicians 22 (4) Number of physicians thus reached 984 (5) Number of circular letters to physicians 8,784 (6) Number of bulletins sent to physicians...... r,0Si (7) Number of physicians treating the disease 279 (8; Number of persons treated by physicians 584 2. Getting the people to seek examination and treatment : (i) Number of schools inspected 238 (2) Number of homes inspected 2,765 19 72 109 200 18 93 88 200 32 71 94 200 00 10 258 268 00 00 202 202 00 30 170 200 2 76 121 200 I 106 121 228 78 128 206 25 175 200 TENNESSEE. 87 (3) Number of families examined 1,437 (4) Number of persons examined clinically 17,574 (5) Number of persons examined microscopically 16,038 (6) Number of specimens positive 5 532 (7) Total Number of persons examined 33,6i2 (8) Number of persons treated by field force 3,842 (9) Total number of persons treated on record S,I03 3. Work of county dispensaries : County. Clay Carter Johnson Washington . White Cumberland . Putnam McMinn Marion Franklin. . . . Hamilton. . . . Amt. of Appro. $25.00 100.00 200.00 200.00 150.00 75-00 150.00 150.00 150.00 25.00 150.00 Totals $1,375-00 3. Work of county dispensaries : No. of persons and times treated. County and Doctor i 2345 Clay Pickett Fentress (Lansdeii). 885 361 lii 24 5 Carter (Yancey) 537 276 125 3 2 Johnson (Yancey).. 220 227 95 3 2 Marion (Lacey).... 492 206 12 2 Marion (Lee) 59 22 i 00 Marion (Robinson). 12 24 16 Franklin (Lee) 37 16 S o o • Franklin (Robinson) 31 31 28 Washinton (Yancey) 68 45 50 00 White (Breeding)... 160 6 00 o o Cumberl'd (Breeding) 5 14 196 9 o o Putnam (Breeding) . 73 16 o o McMinn (Lee) 421 284 145 4 Warren (Lee) 69 40 7 o Hamilton (Lacey).. 264 183 47 14 4 Totals 3,?42 1.933 651 5o 13 4. Report of Laboratory. Duration of Campaign. 30 days 47 days 48 days 32 days 22 days 43 days 35 days 40 days 59 days 8 days 59 days 423 days Total No. Total No. people treat- treated, ments. 885 537 220 492 59 12 31 68 160 S14 IZ 421 69 264 i,38» 943 547 732 82 52 58 90 163 166 7'9 89 850 163 S14 6"!5S6 (1) Total number of specimens examined 897 (2) Number containing hookworm ova 144 (3) Number containing Tricocephalus dispar 78 (4) Number containing Oxyuris vermicularis 12 88 TENNESSEE. (5) Number containing Ascaris lumbricoides 165 (6) Number containing Taenia nana 36 (7) Number containing Taenia saginata 3 (8) Number containg Amoeba coli 78 (9) Number containing Strongyloides intestinalis i (10) Number containing Fly larvae I (11) Number containing Bacillus tuberculosis 5 5. Summary: (i) Number of persons examined 33,6i2 (2) Number of persons treated by physicians 584 (3) Number of persons treated by staff 4,579 (4) Number of persons treated 5,103 III. Educating the people in sanitation. 1. By public lectures : ( 1 ) Number of public lectures delivered 118 (2) Estimated number of persons reached 20,264 2. Through the schools : ( 1 ) Number of teachers in state 9,233 (2) Number of teachers reached by visit 871 (3) Number of teachers reached by letter i,3S7 (4) Number of teachers reached by bulletins 1,167 (5) Number of teachers reached at institutes 2,562 3. By bulletins, leaflets and special literature : (i) Total number of bulletins and leaflets distributed. .59,797 4. Through the press: ( 1 ) Number of papers in state 252 (2) Number of papers personally visited 67 (3) Number of letters to press 66 (4) Number of articles furnished for publication loi IV. Notes on work of the year. r. The State and District Directors have been received by the physicians of the State with uniform kindness and a num- ber of physicians have been very active in their support. It is known that many cases of hookworm disease are being treated by individual physicians after cHnical diagnosis and we get no direct reports of most of these cases. In fact, we have been able to get very few reports of cases treated from the doctors of the State. However, it is believed that the medical profession of Tennessee, taken as a whole, is sup- TENNESSEE. 89 porting our work and we make grateful acknowledgement of the help that has come to us from this source. 2. It has been a constant aid to take advantage of every opportunity to get into touch with the people. The dispen- saries have been our most valuable aid to this end and they have accomplished as much as could reasonably be expected. Five counties made appropriations for the free dispensaries in 191 1 and 15 are now on the list, lo having been added in 1912. Some question has been raised in a number of coun- ties as to the legal right of the county courts'to appropriate moneys for dispensary purposes. In some of the counties appropriations can be made at only one sitting of the court in the year, and none of the courts sit oftener than once in three months. These courts are generally large bodies and the amount of work necessary to get the matter of appropriating money before them with a reasonable promise of successful outcome is not an insignificant matter. The average time con- sumed in the operation of the dispensaries has been greater than we would have it be, but the effort has been to do the work thoroughly and with fairness to every part of each county. 3. The schools of the State have had their doors open to us. The State Suj)erintendent of Public Instruction, the Assistant Superintendent, the State High School Inspector, the Presi- dents of the three State Normal Colleges, County Superin- tendents and other educational officers have been our active allies and have encouraged our work in every possible way. The State and District Directors have been given prominent places on the programs of Teachers' Institutes, Educational Rallies and other meetings of public nature. The County Superintendents have usually accompanied the field men 90 TENNESSEE. through their respective counties ; County Boards of Educa- tion have lent encouragement, and the teachers have nearly all done what they could to help. 4. The Board of Education of the progressive little moun- tain city of Cookeville, in Putnam county, headed by Dr. W. Scott Farmer, has expended $1,500 for sanitary improvement and has established a course of Hygiene and Sanitation in the schools. This course is conducted by Dr. Farmer and other local physicians, and visiting speakers are impressed into ser- vice to help the good work along. Drs. Breeding and West have been allowed to help in this movement. The benefits are already apparent, more than two hundred of the children having been examined for hookworm disease and the medicine for treating those found infected has been given them. This places Cookeville in the lead of other cities of the State of like size in the matter of sanitary improvement in the schools. 5. The little city of Jellico, another mountain town, in Campbell county, has made great improvement in the city school, having put in a sewer system connected with the new city sewer. Medical inspection has been carried out in the Middle Tennessee Normal College, located at Murfreesboro. The examination of the students of the State institution for the blind is now under way. The famous Webb School, at Bell Buckle, has been examined for the second time. Part of the student body at Castle Heights School at Lebanon has been examined. An orphanage lotated in a Middle Tennessee town has had all of the children examined and treatment was given to all infected individuals. 6. A special train for educational purposes was operated over all the railroads qf the State by the State Department of Agriculture and the various railroad companies. One car in TENNESSEE. 9 1 this train was given over to public health demonstrations and an exhibit on hookworm disease and sanitation was given a prominent place. This car was visited by 200,000 persons and the hookworm exhibit attracted wide attention. 7. Bulletins and leaflets have been widely distributed throughout the whole State and many more requests for liter- ature have been received this year than ever before. Ten- nessee Senators and Congressmen have supplied us with gen- erous suppHes of literature which has been used to good advantage. 8. The Farmers' Institutes, conducted by the State Depart- ment of Agriculture in the three Grand Divisions of the State, are large and influential bodies and the attendance has been larger this year than ever before. The State Director has ap- peared before all these institutes. The Department of Agri- culture has been most kind and helpful and has made it possible for our work to be brought directly to the attention of great numbers of our people. 9. County health officers in Tennessee are doing better work than has heretofore been done. The State Health Officers' Association in April was addressed by Doctors Rose, Freeman, Porter, Leathers and Stiles of the Commission's forces. .The meeting was a grand success and foretold good things for the future. 10. Because of an absolute lack of funds since March ist the State Board of Health has been unable to furnish the financial assistance extended in former years. The Secretary of the Board, Dr. R. Q. Lillard; the Assistant Secretary, Dr. H. H. Shoulders, and all employees of the State Board of Health have done whatever they could to further our work and have extended every courtesy to the Assistant Secretary. 92 TEXAS. TEXAS. I. State survey by counties. 1. Infection survey, based on an djen between the ages of from the country: County and Area in Doctor. sq. miles. Pop. Jasper (Ferrell) . . 977 7,138 Angelina (Ferrell) 881 13,481 Hardin (Ferrell).. 844 5,049 Montg'ry (Hoch). 1,066 17,067 2. Sanitary survey, based on an at least 100 country homes : examination of at least 200 chil- 6 and 18 years, taken at random Number Number Per cent. examined. infected. infected. 1,016 ' 603 59.3 1,096 820 74.8 1,114 669 60.6 999 700 70.7 inspection of privy conditions at County and Doctor. B Type of Privy. C D E F Jasper (Ferrell) o ( Angelina (Ferrell) o ( Hardin (Ferrell) o 1 Montgomery (Hoch) i II. Getting the people treated. 9 48 8 90 220 135 2S3 410 Total No. inspected. 229 183 301 509 Enlisting the physicians : (i) Number of physicians in state (2) Number of physicians personally interested (3) Number of lectures to physicians (4) Number of letters and circulars sent to physicians. (5) Number of bulletins sent to physicians (6) Number of physicians now treating the disease. . . . (7) Number of persons treated by physicians Getting the people to seek examination and treatment : ( 1 ) Number of schools inspected (2) Number of homes inspected (3) Number of families examined (4) Number of persons examined clinically (5) Number of persons examined microscopically (6) Number of specimens positive (7) Total number of persons examined (8) Number of persons treated by field force (9) Total number of persons treated on record. . . . 5,789 490 3 6,422 2,500 S19. 3,210 25 4,262 4,262 7,472 3. Work of county dispensaries : County and Amt. of Doctor. Appro. Jasper (Ferrell) $300.00 Angelina (Ferrell) 300.00 Hardin (Ferrell) 300.00 Montgomery (Hoch) 300.00 Expenditures. $220.40 266.80 285.00 287.77 Duration of Campaign. 6 weeks 6 weeks 6 weeks 6 weeks Totals $1 ,200.00 $1,059.97 24 weeks TEXAS. 93 No. of persons and No. people Total No. County and " times treated. treated. treat- Doctor. I 234 ments. Jasper (Ferrell) 803 264 65 o 803 1,133 Angelina (Ferrell) 1,081 303 43 o 1,081 1,427 Hardin (Ferrell) 1,140 339 33 1,140 1,512 Montgomery (Hoch) 1,238 147 21 i 1,238 1,407 Totals 4,262 1,053 163 I 4,262 5,479 4 Report of Laboratory. (i) Total number of specimens examined 834 (2) Number containing hookworm ova 160 (3) Number containing Tricocephalus 10 (4) Number containing Hymenolepsis 7 (5) Number containing Taenia saginata 6 (6) Number containing Ascaris IS (7) Number contaitiing Strongyloides Oxyuris 4 S. Summary : (i) Number of persons examined (2) Number of persons treated by physicians 3,210 (3) Number of persons treated by staff 4,262 (4) Total number of persons treated 7,472 III. Educating the people in sanitation. 1. By public lectures : (i) Number of public lectures delivered 138 (2) Estimated number of persons reached 13,308 2. Through the schools : (i) Number of teachers in state ' 21,277 (2) Number of teachers reached by visit 98 (3) Number of teachers reached by letter 230 (4) Number of teachers reached by bulletins 230 (5) Number of teachers reached at institutes 57 3. By bulletins, leaflets and special literature : (i) Total number of bulletins and leaflets distributed. .38,956 4. Through the press : ( 1 ) Number of papers in state 933 (2) Number of papers personally visited 27 (3) Number of letters to press 125 (4) Number of articles furnished for publication 139 IV. Notes on work of the year. I. Every physician solicited has co-operated cheerfully in the work. In numerous places the doctors have devoted an entire day to bringing suspected carriers and sufferers to our dispensaries for examination and treatment. This active co- 94 TEXAS. -Operation of the physicians has been of incalculable value in making the work a success. 2. Every school teacher and school trustee in the counties where the work has been carried on has been reached, either by personal visit or by letter. The response has been immediate and effective. In places entire rural schools of 25 or more pupils have been examined and from 25% to 100% of the children found infected. All the teachers are anxious to learn about hookworm disease and its prevention so that they may instruct their pupils in this matter. 3. With but singularly few exceptions the county officials are anxious to have the State make investigation among their people. This interest is evidenced by the fact that in six months 15 counties have made appropriation for the county dispensary. 4. The President of the State Board of Health and the State Superintendent of Public Instruction have endorsed a bill to be presented to the State legislature providing that all children attending the rural schools must be examined for hookworm infection once a year by the State Board of Health or present a satisfactory certificate showing that the child has been examined and been found free from infection. 5. The State Text Book Board has recently adopted a text book on hygiene, "The Human Body and Its Enemies," to be used in all the schools of Texas. This book contains an illustrated chapter on hookworm disease, its symptoms, treatment and prevention. 6. In Jasper county the Women's Clubs have recently car- ried on "Clean-up Crusades" in many of the villages and smaller towns. This followed in the wake of the campaign carried on by the Commission. The county health officers of Jasper, "Angelina, Montgomery and Hardin counties are urg- ing medical inspection of schools and laying particular stress upon hookworm disease. VIRGINIA. 95 VIRGINIA. I. State survey by .counties. 1. Infection survey, based on an examination of at least 200 chil- dren between the ages of 6 and 18 years, taken at random from the country : Area in Number Number Perctg. of County. Sq. miles. Population, examined, infected, infection. Bedford 729 30,3S6 251 57 22.7 Caroline 562 16,709 1,848 64s 34.9 Essex 277 9,701 280 iss 55.4 Franklm 690 25,953 883 378 42.8 Greenesville 288 9 7S8 326 212 66.5 Henry 425 19265 1,287 635 49.3 Middlesex 156 8,220 252 65 25.7 Northumberland.. 235 9,846 219 31 14.1 Patrick 489 1 5,403 954 636 66.6 2. Sanitary survey, based on an inspection of privy conditions at at least 100 country homes : Type of Privy. County. A B C D E F Total. Albemarle 3 28 160 18 209 Amelia 138 67 205 Amherst .- 4 90 107 201 Appomattox 2 98 107 207 Bedford ig 132 151 Buchanan 5 87 174 266 Caroline i 27 117 58 203 Chesterfield I 39 152 15 207 Charles City 10 115 89 214 Charlotte 4 106 93 203 Culpeper 6 40 140 ig 205 Cumberland i 93 no 204 Dickenson 15 43 146 204 Dinwriddie I 12 145 50 208 Essex 6 loi 95 202 Fairfax 32 51 139 14 209 Fauquier 3 43 156 14 216 Fluvanna i 3 - 105 96 205 Gloucester 5 1 13 82 200 Goochland 3 78 127 208 Greene i 5 166 56 228 Greenesville 112 96 208 Hanover 6 3 T47 58 214 Isle of Wight. 2 5 126 76 209 James City i 26 106 71 204 King and Queen 164 75 239 96 County. A Louisa I Loudon 4 Madison i Nansemond Nelson New Kent Norfolk r Nottoway i Orange 5 Prince Edward Prince George Prince William Princess Anne Powhatan 2 Rappahannock 3 Spotsylvania I Surry Sussex Stafford Warwick Wise York 2 II. Getting the people treated. 1. Enlisting the physicians : (i) Number of physicians in state 2 357 (2) Number of physicians personally interviewed 365 (3) Number of lectures to physicians 18 (4) Number of physicians thus reached 560 (5) Number of circular letters sent to physicians 6,300 (6) Number of bulletins sent to physicians 8,900 (7) Number of physicians now treating the disease 194 (8) Number of persons treated by physicians 1,627 2. Getting the people to seek examination and treatment : (1) Number of schools inspected 340 (2) Number of persons examined : Clinically 15,227 Microscopically 25.996 (3) Number of persons treated by field force other than dispensaries 3.317 (4) Number of persons treated by dispensaries S.656 (5) Total number of persons treated on record 10,600 3. Work of county dispensaries : VIRGI.\I.\. Survey (Continued.) B C D' E F Total. 8 15s 40 204 49 ISO 8 211 10 172 31 214 10 130 bi 201 S 100 97 202 6 122 78 206 38 145 27 211 3 127 70 201 7 151 28 191 I IIS 90 206 6 149 46 201 31 144 ^7 212 29 148 42 219 4 lOI 94 201 IS 172 32 222 14 130 67 212 6 125 78 209 5 126 81 212 98 102 200 22 123 b(5 211 8 124 95 227 I 16 127 67 213 Doctor and Amt. of County. Appro. (Dr. Bnmifield.) Bedford $roo.oo Henrv lOO.OO Amount used. tiioo.oo 100.00 Duration of campaign. 5 weeks 4 weeks Examinations. Mic. Pes. 1.363 2,563 361 912 VIRGINIA. 97 (Dr. Fisher.) King and Queen Essex Gloucester 100.00 (Dr. Miller.) Franklin 100.00 Patrick loo.oo Caroline 100.00 100.00 100.00 100.00 4 weeks 4 weeks 4 weeks 5 weeks S weeks 5 weeks 276 147 669 307 169 24 4,659 3,776 4.854 1,195 1,666 1,044 Totals $600.00 $500.00 36 weeks 18,329 5.656 Appropriations made but work not yet started: Appomattox $100 Roanoke 100 Tazewell 100 Lee 100 Wise 100 Dickenson 100 Total. .$600 County and Doctor. No. of persons and times treated. 123 (Dr. Brumfield.) Bedford 361 326 20 Henry 912 874 752 (Dr. Fisher.) King and Queen 147 140 19 Essex 307 62 Gloucester 24 2 (Dr. Miller.) Franklin 1,195 1.192 675 Patrick 1,666 1,666 1,662 Caroline 1,044 1,044 i>044 No. people Total No. treated. treat- 4 ments. 361 912 707 2,538 4 147 307 24 310 18 1,195 1,666 3080 4,994 1,044 3.132 Totals 5,656 5,306 4,172 22 5,656 15,156 4. Report of Laboratory: (1) Total number of specimens examined 5.569 (2) Number showing hookworm infection 1,569 (3) Number of specimens negative 3,290 (4) Number of specimens showing roundworm infec- tion 757 (5) Number of specimens showing other parasites 183 5. Summary: (i) Number of persons examined 41.223 (2) Number of persons treated by physicians 1,627 (3) Number of persons treated by staff 8,973 (4) Total number of persons treated 10,600 98 VIRGINIA. III. Educating the people in sanitation. 1. By public lectures : (i) Number of public lectures delivered 410 (2) Estimated number of persons reached 46,850 2. Through the schools : (i) Number of teachers in state 9,000 (2) Number of teachers reached by visit 410 (3) Number of teachers reached by letter 950 (4) Number of teachers reached by bulletins 9,000 (5) Number of teachers reached at institutes ' 2,150 3. By bulletins, leaflets and special literature : (i) Total number of bulletins and leaflets distributed. 165,000 4. Through the public press : (i) Number of papers in state 211 (2) Number of papers personally visited 50 (3) Number of letters to press 25 (4) Number of articles furnished for publication 16 (5) Special articles 200 IV. Notes on work of the year. 1. The State legislature enacted a law providing for the registration of births and deaths in Virginia. 2. The Virginia State Board of Health on January 10, 1912, promulgated the following regulation : "Whereas, many public schools in Virginia are not provided with proper sanitary conveniences ; and, whereas, such condi- tions are dangerous to the health of the pupils and to the public health, "Therefore, be it ordered by the State Board of Health that from and after September ist, 1912, no building shall be used for public school purposes in Virginia unless same shall be provided with two sanitary privies, built and main- tained in accordance with the regulations of this Board. "Be it further ordered that all officers and agents of this Board are ordered to proceed with the enforcement of this regulation in any case of violation of its provisions observed after September ist, 1912." VIRGINIA. 99 3. Every city in Virginia at the present time is making more or less effort to render sanitary every privy within their limits. Roanoke, Richmond, Lynchburg and Norfolk have practically achieved this end, and the work is now going for- ward in the rest of the cities. In the towns much has already been accomplished and progress is continuous and satis- factory. 4. The State Board of Education has approved and made part of the school law the regulations for the sanitation of schools promulgated by the State Board of Health. These have been transmitted officially to all county school boards. The progress already made is exceedingly encouraging, but exact details cannot be given, as the reports of the State Board of Education have not yet been compiled. 5. Number on record of sanitary privies built in rural dis- tricts 310. Several thousands have been built or rendered sanitary in cities and towns. 6. There has been a marked increase in the activity and efficiency of the county health officers throughout the State. In a number of counties salaries have been increased and sanitary work much extended. 7. Through the co-operation of the State supervisor of rural colored schools, February 12 was celebrated in the colored schools of 18 counties as Health Day. The Tuberculosis Catechism of the State Board of Health was taught in all the colored schools in these 18 counties to approximately 30,000 colored people. The supervisors of these 18 counties have agreed to secure two sanitary privies at each colored school. This work has made great progress during the year. Co- operation of the Negro Organization Society promises much for the improvement of sanitary conditions among the negroes. 100 VIRGINIA. A definite scheme of work has been mapped out and is now being followed. 8. Strong effort has been made to secure the building of sanitary privies at railroad stations in the State. The Rich- mond, Fredericksburg and Potomac Railroad has already completed sanitary privies at each station. The Atlantic Coast Line Railroad has built an experimental .LRS privy at Jarratt, Virginia, and has authorized the installation of similar privies at all stations in Virginia as soon as the value of this type is proved. The Southern Railway has submitted plans for a sanitary privy to be erected at all stations along its lines as soon as approved. CHAPTER III. HALF-TONE ILLUSTRATIONS. Fig. 6 — Showing results of treatment, a. Bryan Shell, Arkansas; age 13, very anaemic; sick since childhood; hemoglobin less than 15%. b. Bryan Shell nine weeks after receiving first treatment. Had 9 treatments one "week anart TTpmne-lnHin !'B7o. i5 a O gfe Fig". 12 — Results of treatment, a. Prescott family, Richmond county, Va. ; "Whole family found heavily infected in 1910. The mother had never known a w^ell day; father was doing about half work, the oldest boy almost none. No one of these children, no member of their parents' family, or their grandparents' family, or their grreat-grandparents' family on either side had ever gone to school. Photograph made nearly two years after treatment, b. House in w^hich the children were born and in w^hich the fan:iily had lived up to time of treatment, c. House which the family built and moved into about 14 months after treatment, d. School which children are now attending. e. Boy at fence has made a good crop. He and his father are now using their muscle and energy to bring the family into a prosperity never before known. 0) I I "^ 0) m "^ c II) " t? „ -_, a ■^ -C « oa • t,^ to 0) o a) pa-- C J — "I am informed that your Board is thinking of making an appropriation to eradicate the hook- worm in your county at their next regular meeting, and feel- ing a keen interest in this important work I am taking the ILLUSTRATIVE LETTERS. lO/ liberty to write you about the work that has just closed here. "This county, Lamar, was one of the first in the State to make the appropriation, which they did by giving us $150 at their regular May meeting. Under the direction of Dr. R. N. Whitfield the work was begun as soon as possible and was carried along from week to week until the entire county had been pretty thorougly worked. This being' the initial work in the State we would naturally be a little slow in coming in for treatment. In the face of this Dr. Whitfield treated about 1,700 in about five weeks, and we had some medicine left after we had finished our labors. A part of the appropriation was never needed. I mention this to show you how very little it costs to have this work done. "I have had occasion to investigate some of the good results of this treatment, and one would be surprised to note what a different state of affairs exists already as compared to that of ten weeks ago when this work was begun. We, of course, have not had time to see the best results yet. "The members of our Board of Supervisors to a man say that they have never made an appropriation that did as much for the county as this. They are more than pleased with the results, and surely the medical profession of the county is. Besides this I have never heard one dissenting voice from a single tax-payer. "It might be of some interest to you to state that the Board of Supervisors of Pearl River, our sister county, at their last , meeting appropriated $150 with which to do this work. They were prompted, I understand, more by the good results we had obtained in this county than by any pressure that was brought to bear on them from other sources. "I hope your body will not believe that I am undertaking to Io8 ILLUSTRATIVE LETTERS. get beyond the bounds of propriety when I write this letter, and am sure you will not. I have, as I stated in the beginning, seen the good results of this work and am an enthusiastic ad- vocate of it. I believe that all good people owe it to them- selves and their country to do all possible to encourage and support anything that will be of the best benefit to our people. "In conclusion, I desire to say that if you good people make this appropriation I am sure you will never regret it. The work will be under the direction of a man whom I know to be in every way capable, an energetic and untiring worker, and a man who will certainly get you results. "Asking your indulgence for this rather lengthy communi- cation, I am, Yours verly truly. "Mr. J. E. Odum, Collins, Miss." 3. Letters from members of County Boards of Super- visors and other officials. (i) F. B. Pierce, Chairman Columbus County (N. C.) Board of Commissioners, and F. T. Wooten, County Super- intendent Schools. — "It gives us much pleasure to write you that the hookworm dispensaries conducted by Dr. C. L. Pridgen in our county something over a year ago, in every way gave entire satisfaction. Hundreds of children infected with the hookworm disease were treated, and the decided ben- efits theSe children received are the strongest evidences of the worth of Dr. Pridgen's work. "Even far greater good than this has been accomplished. Our people have become aroused as never before in sanitation ILLUSTRATIVE LETTERS. IO9 and all other matters that pertain to the improvement of health conditions." "Dr. John A. Ferrell, Raleigh, N. C." (2) /. D. Hatten, Member of Board of Supervisors, Sum- rail, Miss. — "I want to say that we had one family on the pauper list that we were paying $12 per month, and, in addi- tion, the doctor's bills. They were treated by you for hook- worm disease, and we have now taken them off the pauper list. They are making their own support, and I could give you many other expressions of appreciation. "Dr. R. N. Whitfield, Collins, Miss." (3) Letter from one County Commissioner to a Commis- sioner in an adjoining county — "I understand that your Board has in contemplation the establishment of hookworm dispensaries in your county. Of course, you know that you do not pay for anything except the medicines and probably traveling expenses of the assistant. If you had to hire this work done and pay for all expenses it would cost probably sev- eral thousand dollars. Having had the service in Craven county (Mississippi) I am particularly anxious that you should have the service in your county. If you could see the thousands of children that were treated in this county for almost nothing, and the great improvement that has resulted from the treatment, I feel sure that your county would not only have the service, but that you would extend it like we did in Craven. There is nothing that concerns your county or is of as much value to your citizens as good health; the children cured of hookworm will produce for your county each year no ILLUSTRATIVE LETTERS. more than you have to pay out. I have no doubt that there are thousands in your county that are suffering from this disease, and they can be cured, and I hope that your Board will look favorably upon this matter. "I am taking this liberty to write to you because you are so near Craven that we feel that we have similar interests. There is one family in Bridgeton, just across the river from New Bern, that was infected ; we think there were five in all ; these children look rosy now, where before they looked like cakes of tallow. We certainly hope that you will not let this oppor- tunity pass, and assure you that Craven county will under- take the same thing next spring if the present Board is re- turned. Kindly pardon the liberty taken in writing this letter, but I am only doing it through my interest in the welfare of the country around this section." (4) S. L. Rhyne, Chairman Board of County Commission- ers, Catawba County, N. C. — "Our people generally were greatly pleased with the hookworm campaign. Not a com- plaint has been heard on account of the small appropriation made by our Board. We are under obligations to you and your department for coming to us with this matter. "If it will be worth anything in getting other counties to take hold of the movement, I will say that our Commissioners and the people were so well pleased with the work of your men after they had been among us a while engaged in this work, that we made an extra appropriation to keep the dis- pensaries open longer. Everybody was pleased with the results. "I believe the schools will now find it easier to teach the facts about hookworm and other diseases. I think our people ILLUSTRATIVE LETTERS. Ill will hereafter be more interested in these things than ever before, for great numbers were treated for hookworm, and now living examples of the good results of treatment are always present. It is a great work. Thank you and your force for this help, "Dr. John A. Ferrell, Raleigh, N. C." (S) Allen J. Barzvick, Mayor of Newton, N. C.r— "The campaign for hookworm treatment in Catawba county has just ended. You have doubtless had many evidences of its success, but I want to tell you that, in my opinion, the County Commissioners never made an appropriation for any work in the county that met with more nearly complete approval than that in this instance. I have recently been in nearly all sec- tions of the county and I heard much of the work of your field men, and without exception I heard only words of com- mendation. "Many of our people have lately been talking of the em- ployment of a competent, progressive physician, at public expense, for all his time, so that this work of health education may go on. I believe this will come, and it would take only about one more campaign like the recent one to bring us the assurance of such health officer. Interest in public health and hygiene has certainly been awakened more by the hookworm campaign than ever before. The work had a wonderfully helpful effect and I wish we could keep up the health work in some vigorous way. "In the town of Newton, after the hookworm campaign got well under way, I found it an easy matter to have all open privies closed and made more sanitary by ordinance of the town aldermen. More Hme and ashes are being used, and 112 ILLUSTRATIVE LETTERS. our sanitary officer finds it easier to keep the town clean, and co-operation is now much more ready in any movement for sanitation. "The many good results of your work in the county can not be told; it has awakened interest in better health condi- tions that will continue to grow. We can certainly see imme- diate results here in the town. A very large number of our people of all classes were examined and, as you know, not a few treated. I will tell you more of the work when I see you. "Dr. John A. Ferrell, Raleigh, N. C." (6) Report of the Chairman of the Board of Commission- ers of Craven County (N. C.) in reference to the zvork of the Hookworm Commission — "The Board ordered the expendi- ture of $300 for medicine to be used in the treatment of per- sons suffering from hookworm. The Hookworm Commission established dispensaries at New Bern, Vanceboro, Cove, Fort Barnwell, Havelock, Riverdale and one or two other places in the county, under charge of Dr. C. F. Strosnider. The total amount expended under this appropriation was $191.13. There were 4,242 examined and 2,664 treated. The value of this treatment is inestimable. No doubt the great majority of the number treated would have been rendered useless, mentally and physically, by the action cri the disease. The pale, weak and inefficient mental and physical sufferers have been replaced by energetic, rosy-cheeked, clear-minded subjects. No doubt our population has been affected by this disease for many years, and this in great part accounts for the mental and physical disability of many of our school children. We recommend that this treatment be repeated in the spring of 1913. ILLUSTRATIVE LETTERS. II3 "The Board is considering the employment of an energetic County Superintendent of Health, to give his entire time and attention to this department, his general duties to embrace inspection of all public buildings and grounds; source of water supply ; to examine the school children for physical and mental defects, such as defective eyes, ears, nose, throat, heart and lungs; to look after the indigent sick; to investigate all' outbreaks of typhoid fever, diphtheria, scarlet fever, etc. ; to deliver lectures on hygiene and sanitation to school chil- dren, and to make such recommendations to the Board of Commissioners and the County Board of Health as will work for the preservation of the health of all the people." 4. Letters and extracts from letters by teachers, school officials and editors. (i) Exhibit from two institutions shotving difference in efficiency which seems to have been caused by a light infection : (a) Average grade of 56 girls who were found infected 77-75% (&) Average grade of 56 girls taken at random not infected 89.28% (c) Of two sisters in this college, grade of one infected 78. % Grade of other not infected 87. % (o) 5 young men not infected (ages 20 to 28), average grade 92.2 % 5 young men infected, average grade. . 89.8 % (&) 5 boys not infected (ages 12 to 17), average grade 84.2 % 5 boys infected, average grade 81. % (c) 25 men and boys not infected, average grade 86. % 25 men and boys infected, average grade 84. % 114 ILLUSTRATIVE LETTERS. (2) A. J. Caldzvcll, Principal Hammond High School, Hammond, La. — "As you suggested, I have observed closely some of the children whom you treated in my school for hook- worms last spring. In the case of a great many of them there has been a decided improvement.^ The little girl in the fifth grade who was so pale and weak as to make it impossible for her to be in school regularly, soon became well and rosy and closed the session at the head of her class. A young lady in the high school was in poor health and did very poor work; this session she is well and is one of our best students. A boy in the seventh grade took the treatment with equally as good effect. I could mention others. You are doing a great work for education as well as for good health. "Dr. G. B. Adams, New Orleans, La.'' (3) Miss Minnie B. Earner, teacher in rural school in Winn Parish, La.- — -"It has not been quite two months yet since these children were treated, but in many I can see a great change. My attendance is better and also better interest and work. Now when the bell rings they are up and out with a whoop, and when they return it is with a flushed face and laughing countenance, showing that they have enjoyed their play. A careful record kept of the progress of these children two months after treatment shows a gain of 5.25% on class work, 8.75% on examination, and a gain of 2% on attend- ance." (4) C. C. Wright, Superintendent of Schools, Wilkes County, N. C. — "It gives me much pleasure to state that the work here in Wilkes county was a most decided success, sev- eral thousand cases being examined, and over one-half of ILLUSTRATIVE LETTERS. II5 these were infected. Much good has been accomplished and the people are well pleased with the expenditure for this work. "Dr. John A. Ferrell, Rakigh, N. C." (5) Extract from editorial in county paper of Hardin county, Texas — "There -were five hookworm hospitals in the county and each one was visited by the doctor six different days. Following are the places and the number of persons examined : "Village Mills, 312 persons examined and 206 found to be infected; Saratoga, 455 examined and 234 found to be in- fected; Silsbee, 567 examined and 361 found to be in- fected; Honey Island, 255 examined and 133 found to be in- fected ; Kountze, 448 examined and 205 found to be infected ; total number of persons examined in the county was 2,037, and the total number found to have hookworms was 1,140, making a percentage of 55 1-9 infected. There were, however, 1,514 treatments during the stay in this county. "In our opinion it was far-reaching and far-seeing on the part of the Commissioners' Court to appropriate the small amount of $300 toward paying the expenses of operating these hospitals in the county and freeing the county of one of the evil infections, which saps the life-blood from the young boys and girls of our country. Three hundred dollars was never spent for a better purpose." (6) W. H. Smith, State Supervisor of Rural Schools, Alissj — "I am thoroughly convinced that the economic pros- perity of the people, the lives and health of thousands of school children, and the progress of educational development of the Il6 ILLUSTRATIVE LETTERS. State depend largely on the successful eradication of the hook- worm. The physical and mental growth of hundreds of chil- dren have already been made possible through this work, and there are still thousands suffering retardation and even stunt- ing of their mental and physical powers on account of the ravages of the disease. "One very favorable sign of the good results from your work is the awakening among school officials as to the need of better sanitary conditions around the school buildings; Many communities have calught the spirit, and are voluntarily pro- viding sanitary privies and taking every precaution to prevent soil pollution. As a result of the campaign work and the bulletins issued by the State Board of Health for use in the schools, the Department of Education, through its field agents and institute directors, is preaching the gospel of better health conditions in every nook and corner of the State. "The fact that the free dispensary at Columbia was a suc- cess from the beginning and was not able to take care of all the applicants for treatment is an indication that public senti- ment has been awakened to the importance of the work. "Dr. W. S. Leathers, Jackson, Miss." CHAPTER V. REPORT OF THE SCIENTIFIC SECRETARY. Addresses and clinics. — During the year igi2 I have given 86 addresses or clinics on the subject of hookworm dis- ease and soil pollution, and, in addition to the foregoing, one of my assistants has substituted for me in lo addresses and demonstrations. Lantern slides. — As the various State Boards of Health were well supplied with lantern slides in 191 1 it has been necessary to distribute only a few new sets this last year. Charts. — There has been such a demand for the charts on hookworm disease and soil pollution, issued by the U. S. Public Health Service, that Congress decided to issue a special edition of 5,000 for use more especially in the public schools. The Congressional edition in question has been published and many sets have been distributed to various colleges, schools and health officers in the infected district. Microscopic diagnosis. — On several occasions during 1912 it has become necessary to place every available assistant at work to help out the State boards of health in an unusual rush in connection with their microscopic diagnosis. In general my office has had much less regular work in the line of microscopic examination than in former years, and most of the cases that reach us now are those in connection with which either practicing physicians, or microscopists con- 117 Il8 REPORT OF nected with the various State boards of health are in doubt as to the nature of the findings. Correspondence. — From the letters that have reached my desk during this past year it is very clear that there is in- creased interest in sanitation throughout the United States; letters come to me from all parts of the country making in- quiries and ofifering suggestions regarding different types of sanitary privies. Index to literature. — In my last annual report reference was made -to an index to the world's literature on hookworm disease, then in course of preparation. This index is now practically completed and enables me to give the references to literature to any correspondent who may desire information on particular .phases of the subject. Field work — Nearly all of my time for about three months of this past year has been occupied in a special study of the children in five rural schools in County Z , in one of the South Atlantic States, and for three months of the year I was occupied with work at the Marine Hospital in Wilming- ton, N. C. For certain reasons it seems best not to give the plans and details of the field work in the present report, but some time this coming spring or summer the facts will be ready for publication. Investigations. — Among the results obtained from recent investigations on hookworm disease, mention may be made of the following: (o) The Effect of Hookworm Disease on the Menstrual Function. — Recently I have had the opportunity of examining into the menstrual history of 129 females in a hookworm in- fected village and of obtaining some rather instructive data on this point. SCIENTIFIC SECRETARY. II9 Among our Southern girls we may find the menses begin- ning at II years of age, or even earlier, but in a considerable number of instances the courses do not appear for some years later. It is very common, especially on the tenant white farms and in the factories, to meet girls of i6 years of age who have never menstruated. The oldest case of absolute amenorrhea in this class known to me was 26 years old. It is also frequent that we find Southern girls who are very irregular in their menstrual periods. This statement holds especially for the tenant whites and factory girls and, to a less degree, for girls in other walks of life. One of the commonest causes of amenorrhea and irregu- larity, especially when it is of the delayed type, is hookworm disease, and experience demonstrates that this fact is too fre- quently overlooked by practicing physicians, especfally by some who have ignored the investigations of recent years and who treat for symptoms instead of for causes. As a very striking case of this kind may be mentioned a 20-year-old girl who had never menstruated ; according to the statement of her mother, she had been under treatment for amenorrhea by eight differ- ent physicians, not one of whom recognized hookworm dis- ease as a factor in the case, although she was a typical hook- worm patient whose real trouble was recognized at a distance of 30 feet. The girl was treated for hookworm disease and her menses promptly became established. According to the statement of the girl's father he has been kept a poor man because of the doctor's bills and drug bills incurred on account of this girl. That the average physician does not fully recognize the im- portance of hookworm infection as one of the many factors in amenorrhea is evident to any person who has had extensive experience with this parasitic infection. I20 REPORT OF (&) Leichtenstern's Method of Judging the Completeness or Incompleteness of Cure. — The late Dr. Leichtenstern, of Cologne, Germany, advanced the view that by counting the male and female hookworms passed by a patient and finding the proportion between the sexes the clinician has a practical clue to the completeness or incompleteness of the cure efifected. If this view be correct we would have in the Leichtenstern procedure a method -that might be of considerable practical value in certain cases that are today somewhat difficult to understand. It has recently been possible to test the method in question by a study of 102 cases of infection involving 13,080 specimens of the American hookworm. The worms passed by each case were classified as to their sex, and it was found that 46% of the specimens were males and 53% females. Of the 102 cases examined, 37 presented an excess of male parasites, 9 pre- sented an equal number of males and females, and 56 pre- sented an excess of females. Leichtenstern's method is based upon the premise that the female parasites are always in ex- cess of the males in a fairly constant proportion. Whatever may be the exact facts as applied to the Old World Hook- worm {Ancylostoma duodenale) , it will be seen from our in- veftigation on the New World Hookworm that the premises as based upon Leichtenstern's theory do not obtain in the 102 cases of infection with Necator americanns examined. The conclusion must therefore be drawn that Leichtenstern's theory is not of 'practical application to our hookworm cam- paign in this country. {c) Treatment. — The standard routine of treatment for hookworm disease is as follows: SCIENTIFIC SECRETARY. 121 First day 6 or 8 P. M. Epsom salts. Second day 6 A. M. J4 of the total dose of thymol. 8 A. M. >4 of the total dose of thymol. No breakfast. lo A. M. Epsom salts. Noon. Light lunch. During this past year I have had occasion to follow several hundred thymol administrations and to notice the symptoms of which the patients complained, and also to notice the nature of the stools that they passed. The studies in question have led me to adopt in my own work three modifications of the standard routine of treatment. First day, Epsom Salts. — The Kentucky State Board of Health recommends the use of salts on the evenings of two days preceding the thymol. This recommendation has a great deal in its favor, although in my own personal experience in North Carolina I seem to have had less success in getting the people to take two doses of salts at their home. For about two years I have been testing a somewhat similar modification, as follows : 5 P. M., Epsom salts, followed by copious drinks of water; 6 P. M., light supper; 8 P. M., Ep- som salts, followed by copious drinks of water. Up to the present time I have not reached any conclusion as to whether either one of these methods, namely, two doses of salts on the same day or on successive days, is superior to the other, but I have reached a very definite conclusion that much of the complaining made as to the weakening effects of the Epsom salts is due to the fact that the people do not take this drug properly, and that if more detailed instructions are given on this point there will be less complaint in regard to the salts. 122 REPORT OF Salts can be given in concentrated solution, that is to say, dissolve the salts in the smallest quantity of water possible, one (i) tablespoonful of Epsom salts can be dissolved in one (i) tablespoonful of water. This reduces to a minimum the amount of unpleasant fluid to be swallowed. Immediately after swallowing the concentrated solution of salts it is highly desirable to drink abundantly of water, be- cause the salts are dependent upon fluid for their successful action, and if this fluid is not supplied it will be taken out of the blood, and thus the patient may experience unpleasant effects. If, however, abundance of water is swallowed the patient usually experiences very slight, if any, effect from Epsom salts. It does not seem wise to give water so abundantly after the morning dose of salts following the thymol. Division of the Dose of Thymol. — For practical as well as theoretical reasons, in order to increase the element of safety to the patient, I have adopted the regular routine of giving 1-3 of the dose of thymol at 6 A. M., 1-3 at 7 A. M., and 1-3 at 8 A. j\l. instead of J4 at 6 A. M. and J4 at 8 A. M., as usually practiced. By the three-dose method we obtain the same number of grain-hours for the drug in the intestines as by the two-dose method. In cases, however, in which we are dealing with a patient who shows an idiosyncrasy to thymol, or in case for any other reason symptoms of thymol poisoning develop, the three-dose method presents the advantage of enabling us to discover the idiosyncrasy or symptoms more promptly and at a time when a smaller dose of thymol is in the system. It further enables us to give instructions to the people who take the dose home whereby they may regulate the dose more ex- SCIENTIFIC SECRETARY. 1 23 actly. For instance, suppose a patient is to receive 30 grains. By the old method he would receive 15 grains at 6 A. M. and 15 at 8 A. M. By the three-dose method he would receive 10 grains at 6 A. M., 10 grains at 7 A. M., and 10 grains- at 8 A. M., but if any unfavorable symptoms develop after the first dose he can omit the second and third, and if any un- favorable symptoms develop after the second dose he can omit the third dose. After trying the two methods on a number of patients I am very decidedly in favor of the three-dose method. Diet. — Nearly all persons who treat for hookworm disease warn the patients not to drink much water and not to take any food until noon on the day they take thymol. In following out this usual practice with the children I have experienced a great deal of complaint, and in an effort to make the children more contented under treatment, and therefore more willing to repeat the dosage when necessary, I have mod- ified the usual procedure as follows : During the morning of thymol administration the patients are permitted to swallow water only in very small amounts, if any. It is of course nec- essary to let them have some water when they take their cap- sules. At about 9 o'clock in the morning, namely, one hour after the third thymol, the patients receive a cup of coffee, without milk ; and at 10 :30, namely, about one-half hour after the morning salts, they receive one or two cups of coffee (with- out milk), but with crackers. Since institiiting this modifica- tion I have had much less complaint on the part of the patients, and I have not been able to discover that the procedure inter- feres in the slightest in the treatment. Sizes of the Doses of Thymol. — Very frequently some author urges that the dose of thymol be increased above the dose now usually accepted as standard, but conversation with 124 REPORT OF our field men seems to indicate that they prefer not to increase the dose. Statistics on the hospital cases at Wilmington lead me to concur most heartily with those field men who prefer the smaller doses. Observation shows that in a considerable proportion of cases the patients are cured with 1-3 or 2-3 of the standard dose, and certainly in such cases it is unnecessary to increase the amount of thymol given. Subjective Symptoms. — An article will shortly be published g'iving the subjective symptoms noticed in several hundred thymol administrations. The summary of the cases is not quite ready for insertion in this report. (d) Blood Pressure. — One of my colleagues, Dr. Worth Hale, has recently taken a number of blood pressures among hookworm patients before treatment. It is proposed to repeat the tests a little later, after the patients have been treated."^ Results will be reported upon later in the year. (e) Chemical Work on Thymol. — Like many other drugs which have found particular applications in medicine, the use of thymol for the treatment of hookworm disease has had a more or less empirical development. As compared with various other drugs which have been suggested as vermifuges, experience has shown that for certain cases thymol has certain advantages over practically all of them. Although this com- pound has proved very efficient in the hands of competent per- sons, its careless use is attended with certain dangers, and, as has been frequently pointed out, there is great need for a safer and more efficient remedy for hookworms. One which could be taken without special precautions, without diet restrictions or accompanying purgation, would undoubtedly simplify im- mensely the successful eradication of the hookworm scourge. SCIENTIFIC SECRETARY. 1 25 It is possible that such a drug may at some time be accidentally discovered in much the same way as thymol was selected, but there is undoubtedly much greater possibility of developing such a remedy by means of careful laboratory studies. It was with this object in view that the chemical and physiological experiments here mentioned were undertaken hy two of my colleagues, Dr. Atherton Seidell and Dr. W. H. Schultz, in the Hygienic Laboratory of the U. S. Public Health Service. As preliminary to a rational search for a better vermifuge than thymol, it was realized that more information in regard to the method of action of thymol itself was necessary. The most direct way to gain information of this character is by ascertaining to what extent and in what form the administered thymol is discharged by the body. Studies of this character require, first of all, a trustworthy analytical method which may- be applied to the determination of thymol in such products as feces, urine or other secretions of the body. A search of the literature indicated that three methods of possible applicability to thymol have so far been proposed. Studies upon these, however, soon indicated that none of them could be made to yield reliable results. From an analytical standpoint the quan- titative estimation of thymol presents difificulties particularly on account of its extreme volatility and the instability of the few relatively insoluble compounds which it forms. Methods based upon removal by precipitation, filtration and drying to constant weight, of thymol itself or its compounds, are there- fore excluded, and it was necessary to resort to reactions which could be measured in dilute solutions. After quite a long series of experiments a method based upon the reaction of thymol with bromine was developed, but its application was limited to aqueous solutions of thymol free of other sub- 126 REPORT OF stances which might also react with bromine. Fortunately, however, the extreme volatility of thymol with steam per- mitted its removal from most interfering substances and in connection with steam distillation the new method has so far been of very great service. In seeking to apply the newly developed method to the several body waste products, attention was first directed to the feces, since according to most preconceived conceptions of the action of thymol on intestinal worms it was expected that a very considerable amount of the administered drug would be found unchanged in the feces. In applying the method to feces a number of difficulties were encountered due to volatile products other than thymol. Provisions for retaining these were introduced one by one, and finally hydrogen sulphide was itself held back by means of a lead salt, and a perfectly clear and nearly odorless distillate was obtained at the end of the multiple steam distillation apparatus. Control determinations were made upon the feces of dogs which had received no thymol and upon such samples to which known amounts of thymol were added. The results showed that these added amounts could be satisfactorily recovered. Thymol was then administered to a series of dogs and the samples collected and analyzed according to this method. The results showed that less than lo per cent of the administered drug was excreted unchanged in the feces. It must therefore be concluded that_ about 90 per cent of each dose of thymol is either decomposed or absorbed from the alimentary tract, a proportion which was certainly not anticipated on the basis of clinical observations. Following the analyses of the feces, efforts have been made to determine the thymol in the urine. Greater difficulties have been encountered, and so far the last of these have not been SCIENTIFIC SECRETARY. 127 overcome. The work has shown conclusively, however, that free thymol does not occur in the urine, but only combined or, what may be considered, neutralized or non-toxic thymol is present. This neutralizing agent, glycuronic acid, appears to stand ready to render harmless the poisonous thymol, and takes care of it all unless it is supplied too quickly, as may occur when oils or fatty substances are also present in the alimentary tract. In connection with this effect upon the absorption favored by oils, a series of experiments has been made upon the dis- tribution of thymol between water and oil. It has been found that for most of the edible oils the ratio of the solubility is about as i to 400. Therefore a given amount of thymol added to a mixture of equal volumes of water and oil will distribute itself so that only i -400th of the total amount remains in the water. The presence of dilute acid, such as contained in the gastric juice, would diminish even this small amount appre- ciably. It would appear that under ordinary circumstances the rate of absorption of thymol from the alimentary tract is taken care of by the neutralizing action of the glycuronic acid, but when oil is present the acceleration may be too great and serious poisoning result. One other line of investigation which is of more general than of particular interest to the thymol treatment of hook- worm disease may be mentioned. It was found that in com- paring the toxic dose of thymol administered in various ways, the subcutaneous injection of thymol dissolved in olive oil was least toxic of all. Observation indicated that absorption from the oil was proceeding extremely slowly, and experiments were therefore planned with the purpose of measuring this rate. The results showed a strict parallelism between the partition 128 REPORT OF coefficient between the oil and water, and the rate of absorp- tion within certain limits, when equal volumes of the solution of thymol in different inert oils contain equal amounts of thymol, the rate of subcutaneous absorption is proportional to the relative saturation of the solvent with thymol. Some of the results in the foregoing studies are exceedingly suggestive and open up a possible change in our conceptions concerning the mode of action not only of thymol but. of other anthelminthics also. (/) Biological Work on Necator americanus. — My col- league. Dr. W. H. Schultz, has performed nearly i,ooo experi- ments with a view to ascertaining more exactly some of the factors which determine the geographical and seasonal dis- tribution of human hookworms in the United States. These studies, it is hoped, will throw additional light upon the forces that co-operate to enable the eggs to develop into mature larvae and the latter to find their host and complete the life cycle. They deal with some of the barriers that Nature, has thrown about the host, which, if taken advantage of, may aid in the avoidance of infection. Dr. Schultz has systematically studied the reaction of the eggs and of larvae to various inorganic salts, to gases, acids, alkalies, and has determined the killing power of a number of relatively cheap disinfectants. Many of these substances, especially phenols, coal-tar derivatives and free chlorine kill both the eggs and larvae in a relatively short time, so that in cases of emergency a number of these substances might per- haps be of use in sterilizing human excreta, or moist surfaces upon which motile larvae have crawled. Many experiments have been made with thymol, its deriva- tives, and with various other vermifuges. The relative toxicity SCIENTIFIC SECRETARY. 1 29 of these substances has been worked out and considerable attention has been given to the physiologic action of some of the more efficient remedies. This same investigator confirms our knowledge that high and low temperatures, drying, and bright sunlight are Nature's most potent agents in kilHng the eggs and larvae of Necator americantts and is able to add new and definite data on this general subject. For example, it is found that temperatures above 42 °C. soon render the larvae weak, inco-ordinate or motionless, the effect being proportional to the increase of temperature and duration of exposure. So that larvae that have been exposed for an hour or longer to a temperature of 46 °C. are either killed or so injured that they are unable to infect the skin and they die soon afterwards, whereas larvae exposed for one minute to a temperature of 5o°C. are either killed within that time or die a few minutes later. He is now extending his experiments to physiologic minimum temper- atures. Part of Dr. Schutz's results will be sent to press in the near future. Publications. — During 191 2 a number of manuscripts have been prepared, and several more that are based upon work this past year are now in preparation. The following manuscripts have appeared in press : ScHULTz (W. H.") and Seidell (Atherton) : 1912a. Subcutaneous absorption of thymol from oils. < Original communications, 8th International Congress of Applied Chemistry, v 19, pp. 271-278, i fig. 1912&. The determination of thymol in dog feces. < Ibidem, pp. 281- 286. Seidell (Atherton) : 1912a. A new bromine method for the determination of thymol. 130 REPORT OF SCIENTIFIC SECRETARY. salicylates and similar compounds. -^O cCO r3 CO OO r~ W3CD i-iT*< i-iO •*CO COi-i »-i OO £ §J §■§ §J § £ iq£ ib5 h5 hS wS hS w£ h5 h5 h5 Hw h 5 o o O K GENERAL SUMMARY WITH NOTES 29 § SS6§656S656?fe?6S6§6?6S 6? ^1 Clt^XCOCOOOTiHiOCOt^tN CO ri LOCCt^CO-^-^-^-^-^-^CO ■* < ^■i J HH o s o (N-*mCn-*01NOO(N05 o ^ or*»Oi-HicOi-ico'^CT)to »o ■<; OOCDOT-Ht^wCOOSi-lT-(i-H IM ^ ■ S COt^CO00r*CO(N00-^00"3 lo" m g .-HT-ti-HOOCOCDOi-tt-l'-HC^ T-H 1-t -■iH O « <3 H J M 00 ^ -g O W CO.tO CO (N CO 00 (D ■* C» (N NrHOOOlOt-COCOCO-^OC C<1 ^ Ot>05C0rH(N CO s 00 T-H (N ■* tH 0_00 CO -* c32 to t^ K a >ra 1> 1-1 TjTio O t-Tt-TiN 00 CTi o C o H o » 1 Q H 1 ?l 02 .« P'd "a 1 R o o < s < .1 a Is i ■i i 8- > J .so GENERAL SUMMARY WITH NOTES Table 5. — Sanitary Survey, 1913. State Number of Surveys Made* Number of Rural Homes Inspected Alabama Arkansas Georgia 11 10 21 18 19 32 33 16 19 20 5 2,253 5,110 5,507 13,048 6,813 Mississippi North Carolina • 20,805 10,893 3,888 Xennessee . . . 4,930 Texas Virginia . . 7,925 1,029 Total 204 82.201 Table 6. — Sanitary Survey — Number c / Countigi Surveyed by Years. 1913 State No. of Counties 19 in State 10 1911 1912 (by quarters) Grand 1 2 3 4 Total Total Alabama 67 .. .. 9 15 3 3 2 3 11 35 Arkansas 75 .. .. 11 10 2 2 2 4 10 31 Georgia 148 .. .. 10 14 6 4 5 4 19 43 Kentucky 120 .. 8 9 3 6 18 26 Louisiana 64 .. .. 10 11 4 7 3 5 19 40 Mississippi 79 .. .. 5 24 4 8 5 13 30 59 North Carolina. . . 100 .. .. 43 20 10 8 7 8 33 96 South Carolina. . . 44 .. .. 4 22 8 2 3 13 39 Tennessee 96 .. 14 9 1 6 5 6 18 41 Texas 249 4 3 6 6 5 20 24 Virginia 100 .. 14 48 4 1 5 67 Total 1,142 .. . . 120 'l85 37 62 40 1 57 196 501 *Eialit second surveys included. BY THE ADMINISTRATIVE SECRETARY. 31 T3-3 o OS 00 m (M T— ( rH t^ CT 00 lO CO ■* tH lO Oi 00 Oi CO (N O O no -* (N '^ o CO t~ r- T-( lO CO lO •a 00 00 CO l> T— 1 (N lO o (33 03 CO 03 1— t r-i "" IN CO 05 1— I rH rH e3 O W < e P m S 03 CO o lO »-H (M rH T-H CO 00 rH <0 00 00 o (N rH CO rH . IN "5 rH Tt< lO lO 03 O IN rH ^ CD (N ■* C 32 GENERAL SUMMARY WITH NOTES 1 Q Oi 00 CO N t-H I-H t>. N 00 lO to 5 TtH ■a (» 00 a> CO (N o 00 11 N '^. o CO l> t~ iH lO CO lO lO 00 CO m t>r ^ ci ta o 03 oT CO OS 1-1 *H *-) cq CO CO I-H I-H 00 5h I-H CQ a •e. OS CO o o 05 00 to IN CO CO ITS 00 |H| M o lO CO t> •* 00 00 I-H w> 00 >* (i(. to **- oc 00 t> ■* cq co_ ■* to cc OS ij CO i-H ec 00 t-^ 05 oT Ui to" ■* ta U3 s »— 1 i-t iH OS ->! p to CO o N (N CO CO to t- I-H o to t> o i> CO 00 f-H to U5 to to •a P4 to oc o lO IM 1-( (N to 00 05 •^ 1-H 1 ■^ CO OJ to N CO to" ■* N (N i> fe »-l I-H 1-4 00 > K Ph CO I— t 1> O CO r-^ o 00 (M o; S2 O l> w t^ CO rH (N I-H r~t ■* 00 o "*. o •-H N (N 03 to lr~ rH T-H ■* > s 3 ■< tg g CM a 5 § o t> « O (N to o to CO IN H s lO I-H 00 I-H CO •a I-H a I-H ■* o M (4 o K H n S P fe . ^ H o o; « B CQ _C .g "c "c "o I 1 i 5 i: ii 3 U 4 h- 'I 1 ! 'i . i ! 1 < cc E- .t > i E- b 1 GENERAL SUMMARY WITH NOTES 33 Table 9. — Dispensary Summary. Number of Counties Appbopbiating by Years. 1913 States No. of Counties 1910 1911 1912 (by quarters) Grand in State 1 2 3 4 Total Total Alabama 67 1 10 15 5 2 3 5 15 41 Arkansas 75 1 3 5 5 10 20 24 Georsia 148 ?, ?,1 5 5 7 a 20 43 Kentucky 120 7 2 8 4 1 15 22 Louisiana 64 .... 8 10 1 6 8 4 19 37 Mississippi 79 1 9 27 5 9 8 4 26 63 North Carolina. . . 100 17 41 11 1415 40 98 South Carolina. . . 44 3 19 6 5 5 16 38 Tennessee 96 6 9 3 3 3 6 15 30 Texas 249 100 3 14 13 2 8 3 4 7 7 21 10 35 Virginia 26 > Total 1,142 2 59 179 40 68'69 40 217 457 Table 10. — Dispensary Summary. NuMBijR OP Counties Having Dispensary Work Completed by' Years. States No. of Counties in State 1910 1911 1912 1913 (by quarters) 2 3 4 Total Grand Total Alabama Arkansas Georgia Kentucky Louisiana Mississippi. . . . North Carolina. South Carolina. Tennessee Texas Virginia Total 67 75 148 120 64 79 100 44 96 249 100 1,142 46 16 4 18 6 10 23 38 20 12 4 8 12 12 21 12 20 26 39 16 15 20 13 37 17 40 18 35 57 92 40 27 24 24 159 38 51 66 51 206 411 34 GENERAL SUMMARY WITH NOTES ■ < •m en ^ S g> a I w §•►: T "^ . i-t —I Bi ■-1 O O El m — lO;. rHl0(Mt-OC»C0--l(N CO OO-HN-^-^OOOtD-^Ol.tO t~ 113 I>r rH th" >0 C5 1> t> cq 00 oT i 5h (N'-ICOtOCOT-ITl4-*COCOT!t 005rtl>OOTHCOO tH Ta «>CO.-ICOOOCiOCOCOm(M CO -^ ^ •^ 'I "^^ ■* "l °l '°, ■* '^- ■*. '^- N oTt^rtoo-^or-^tCcooo ■*" i-t,-HT-l»OCqcOOCO(NOOCO -icooa»tot-co lO (N T}( ,-1 >-i O t- -si |l ■* 00 o ■*_ (N Oi^ (N o CO ootDTtTcsi'tCcBio'o'oot- •* ■* n i-H t-H T-l 03 § •05l>050005OIN"3O-*Ca (M.iO (N 3 CO OOtOCO-^'OOO.-IOa'OCC-* I-H lo t-T co" CO ^-^ CO ■* en t>." CO o o" >i CO (M CO (N CD ^ T-l CO t^ O 00 OS »o t>- I- 4 1-t i-H b* lO rH T-H 'iiooooasNrHiootoos Ol T-1 OOCO o ■ ■* CO •* ■* ■* 00 to OO" lO 05 "5 co" r-( C<1 (N •1 .-1 t~ •* CO t~ U3 o t^ 1—1 1* 00 CD (N CD —1 .■ 00 . t-" CO CO (N 05 CO .- _ 05 CO y— 1 CO ■* 00 00 oc i-H CO CO .-1 (N * t~ • ^C ^_ H o a CD O CO 1^ 00 6 N CO lO ■* -! CO N CO lO 05 CD O o fe'-' o o c 00 o cq (N o ■* 1* la 2 a> •S'-H CD ira Tt o o CO o oj 00 d co" Ph i 1— ■-1 •* Tj( r- 1— 1 -H 1^ t^ Oi a •* (M IM ■>* 00 o oi -J" w CO o ^ O CO CO CD N CO 1— 1 (M •o c _ O t^ lO t- O ■* CO t—( OS - i-H Til ■* Tt ' 00 CO CO 00 05 00 00 * 1— CO 1- o CO OS t-H (N CO CD (M l-l 00 1-H (M o 1—) Oi y-\ a c .c ■i IJ 1 ) a 'I ' c 1 <^' "s ^ 1 "3 g o ) ^ 1 1 5 ■ ^ c g •I > H GENERAL SUMMARY WITH NOTES 35 lO to ■* ■* lO ■* lO ■* OS 00 OS CO |3 Tl< -^ rH 00 rH W Q O to r5 lO . IN rH lO T)l ;o O lO o ■* IN OS OS to i-H I-H (M t^ Tj^* U5 rH o ■* J-t 1-1 UD I—i j_, to oa 00 cq lo o OS lO ^ r hIo' "3 CO ■* 00 (5; td o 00 OS (N 00 c^ cq Toti t^ ■* r- o 00_ tD_ IN o t~ O O l^ CO s rH (N CO oo" rH- 00- g- 00 CO Oi l^ 00 c 3 OS rH Tj< to lO o Itl OJ t^ ■* ^ O rH O lO o to to TJ1 iH OS 1> rH lO ■* l> rH CO J> OS (N T-t t^ CO CO Ol t- to 1> o O OS OS •* t- 00 o to to 05 o r- OS 00 CO ■* w g CO I-H 00 CO W CO to <-* »- 1 ^.. ■e to" (N (N s r~t 3 05 to o a 00 00 t^ I^ CO OS c q 00 rH (N »o GO OS to ■* "3 CO c IN (N rH 00 r- lO ' CO ■* OS rH rH T 1 'R. m oo" » rH q to rH Ol - 1— t ■* rH U5 o o ■^ rH OS o c 3 W) CD CO IN to IN O 3 ■* t-H I— 1 "T. O (N O 1> (N to c I "'. ^ 1 00 rH rH N r-t •^ >! o" c-q c ■* O lO to CO OS lO •o -* Tf 01 * 3 CO ""co w O (N o >0 to (N lO o CO Cf 3 . IN b-^ OS to t^ o rH C 00 CO >o 00 o I °i Oos s- 00 rH IN CO t^ ■* rH a s CO CO OS lO to r-i t- ■* o S rH (N' CO 00 to os CO t£ ) OS 1—1 to 05 t~ 00 00 If '. '°. OS 1— 1 (N CO OS If 5 y~* "3 CO o w t- • o ■* .-H 00 o rH o • tc l> .—1 T-H CO to c- 10 o> 1—1 tH o IN -^ § N o OS T-t d o OJ Tj- ■* 00 . rH ■* OS "*. i Oi 1—1 J-t t> OS 1 n ce u 1 c 1 ^J 'S ■ s a cu .0 "d ^ § 1 1 < 6 i -3 g :z g 1 ■5 1 3 o 02 I s ^ ■3 36 GENERAL SUMMARY WITH NOTES a o g o § o CO ffi •^ I n p -c*INCOi-IOOtOCO'«O(N or- o CD to N t^io •* .-1 00 (N'-l(MI>(Mt^O'*!Ne<3CO OWIMCOOSCOOSOOCOOO t^CCCSSCD-^C^^OCOOOOCO ^TtlCOi-l02>OOC05CCOOO ooco»oiot^o»0'-io;t*'^ lNO00iO"3r»(NU50iC0CO rtcocoi>cDOcDiNcqi-iai Ot^lNl^cOMiOCDr^TtOOOW*CDr- 00T-iOCD000qt^05>OO(M M CO CC,CO T-H (M TjH 00 00 O 1-1 •^CTl »oco»ooscoo»oooo (N (Ni-l 1-1 C0'*(NiO'-'t~00'*CD«OO CO CO CO Ot^ 00 00 00 05 1-1 00 OJi-tlXNCDThOSOCOiOO 1-1 •*Qomo3 0-i^ iH CO ^H iOO»0»CO>020005(Mi#0 COOCOlOi-100000005-* O3cor-OOOOCDCO(MCO CD CO »0 CO CO T-H -^ O 05 Oi C<|-*i-l-*00i-li-l OOCO(N(NOi 050J •*OOI>C0i-i05(MCC _Q CO (NOOCOOt^ CO 00 1-1 coo COC^ 00 1-tcO ii .S " o3 »^ - »j ..-, (B.iu sa.° o ■" «•- cj'S 5: o .&0 .11 .S o OS . CO ta • Ot3N d ffl q •33 "^ a)OJ ■ ^ S o a - 03 M °^ V 0) cd <^ " - -3 d ° «« s §.2 - ."^ ■♦^ M ^, rt f-H O Q '^^ e O O 03 ° ^ ^^ •c »^ - -c2 tf;^ a GENERAL SUMMARY WITH NOTES 37 o5iOTt(T)i->*io50owiooo<: CC 1 M osrtMTi'comioioc-imc 'It* CO-^OSQOi-HNXCOCOCCOC CT< • o^ CO CTJi-ICOtOOSCOr-i.- CO CO t~ ^ to 1- t^ 00 I> to "3 CT t- o "3 t^OSOOS-^-^i^COCDOCOlf to OCO-OTitoOtOOOOiO"- OJ X CO O CO i-H t^ 1- 1-1 to 05 tc 02 r-t I— 1 »— CT I-H I-H I-H c c u- o o >o c ^ o ■>* tc t> Tt iC CO CD 00 lO C» »0 t> c to ^^ ■* 00 o: cc Tf 00 CT . p: 0> CC CT CC to 3 (N CT CC CO CC CT CC — ^ g l> cc ■* CT CT c »-H OJ CC 10 CT 1-H' C n tc t> CT CC c OC CC CC ■* o- CO ts J3 CO u: CT c rf CC Ifi c a> i> c Tt< CT CT C CC w; CD CC r- rH ■^ CO £ — ■ •ttl C<3 i-H 1 s 05 c ,_ C CO ■^ c CO U3 — Tf o- QJ CT a- & tc s OC CO OC C ■^ IC N. CT i> CT w" CT tl7 1-H CT CT ■5JI c t~^ s s IN to g c ^ CO CO _ OC o- CO ri 00 ^ OC tc w: to r-( t^ CT -c OC CC " I-H O CT 1> tc CT co" 1^ CTl — M ° ^« IN y~ OC CC 1> »H r- c OCr l-^ 00 CT CT CT tr. OC o- CT O" CT o- li: 00 K c: a CO o If. o- 10 t- CT CT PJ -* e- c tc OC »■ OC CO cc ■* CC oT fi CT t-H rf to CT T-H IN ■< 9 «: ■* CO w; CT CT Tf c OC to T-H w o: 5h tr. C IC CT o- »o CO T— 1 OS I-H o- t- CO c CO tc - ^ CO 1> *" CC CT CC 10 lO ctT '" CC ^ CT lO T-H o cc i> r- CT a- a- 1^ IC CTl I-H c: x OC CT i-H CC a lO I-H CT CT >c CO CT Tf 10 l^ 05 1—1 lO CC Tf t^ CT to" CT to b IS o T-H I-H oj C C c 1 CO £ < S CT -. IS 'c _c *5 . 1 ■ P 1 9 oi < 1 c a _5 c ^0 *5 c CC 1 rr o: a E- 1 > D 38 GENERAL SUMMARY WITH NOTES 1 1-( CO 00 o 1— t 00 I-H ■* (N lO I-H •^ 11 OH ■ tH I^ rH r-< 1> I— ( 1-H 1— ( I-H CO . 00 ' CO o CD i-H ■* ct" CD CO 00 03 rH ^ »-t CO in 1-H 1-H >o CO c T— I 'jH CO (N lO ^ r- cd ■ (N CO (N »-H I-H CO I-H -fj CC l> 1> o CO CVI co_ O • H CO 1—1 lO CT ■o lO rH ?— 1 I-H =2' (N I-H 1 CO I> CO t~ CO ■* lO lO o ■* I-H 00 CO 00 •o uz 03 r-H CO o ' ■* 00 t~ tt> CO cE 05 00 <^ (N T-H I— 1 lO 00 I— I lo ,_^ I-H S 'm' IN &3 CO PS < ■g to o IN T)l •* CD N iO CO CO l^ T-H CT CO (N c= 05 I-H ■* 1-H IN •*" >> a 1^" g < M tH CO 00 cq CO lO lO T-H o CO ■* CO CD CO T-i (N 00 o I— t .". C-l lO g S T-l 1— I CO co" IN I— 1 I> ■* 1^ CO U3 i-H ta 00 CD S2 00 f-H t^ T— I t^ ■* •"^ 1-H CO CO §.Q o U5 cc uz c o ■* 00 ■* O o j^ ■*^M 1— ( 7- ir. CO c; CO lO CO •* ■^ o cc lO o 5 I-H cc CO CC CO £ •" o -* CO c^ t^ 1— 1 X 1> c< 00 oc £>: cc 05 E-i la a Ph i-H Tt P3 05 1 1— t I> IT CD 1* CO . t— T-H •* o o o 1—1 -o Oi 1-1 oo" 00 a a; 02 £ a 1 1 c i 1 1 cr j - .2 i 1 < r 1 3 t 1 3 ts I -5 c D 1 J3 4 q o: 1 1 > GENERAL SUMMARY WITH NOTES 39 2 o o il I § I- 6. O c3 J2 fc P Hi o o 03 Tj1CO00T-'C0'^i-H ICOOOCOCOOOCOW'-KNi-l O 00"o IC oTcD CO t^ iC 00 o tJ* tJ< CD tJ< 05 "^ -^ t-I rH C^I OascCi-HiCcO'^CDCD»-t(N t^C0l>-C^Q0C^Q0OT-t|>.00 I>OOOCO(OOS»0»-HIO-«*<0 CSTjiOiCiOO3CO00b-00cDl>.lC t^IVOSiOCOiOCDC^^iOCC'Oi ^ 00 po t* 1-4 »n lo 03 00 -1* »0 00 CO (M (N 00 00 « CC oo-d^cocor^iOCTn^ooooo coTjooot>wos OOCTiO'-lOOlO'^INOllOCN tD-^00«HOC0'-l'*'*00«> i-HCONOcOOicDOTOWOO C01>U5 OOO w > s "5 ^ 13 fs t a s "S a .s o M S K s 0) OS :S s ?i CO i 3 i- n ? d ^ ^ 5 X "c ja e «> fl JS 7^ a Oi (n s o ^ 01-OCi3-* ■* !^ g S coost^cD-^rHOc^T-iwo r* _ h fl rH TO (N CO to" 00 ■* lO lO rt oT i-H o ^ o l-l f-Hl-Hl-lTt<'CCO'--(tHf-t tH (N Eh o- m 1 No, rson ted l>"*lcO.-ll>00I>!D>OINt^ O t~0300J-*Ttlc<3CDOCO>Ci CO OC<30- .a 02 o CO CD 05 ■* O IN SI (N CO WON ■* 1 »-( 05 T-( r .. & H < S 5 i 05 .-1 ■* CO ■* CO t~ 00 '^ ■* CO o ■ m to CO -^ (N l-l (N IM w CO CO a> "3 lO t^ O 00 lO t^ CO »o 00 ^ rjT CO t^" 01 CO co" H »— 1 I— I tH H E=. o IS c^t^i-*oo>o*ooi-HcDr*o 00 m tDcoio CD n o ioioOi-ioo"* ■* i-H r^ 1—1 T-1 ^ W to Case Report Treated Physioii .-1 TtH 00 -* lO to T)l_ to lO (33 CO 00 00 M Ol" lo" (N ^" m" im" .-T ■* l>r 03 T—t Tl< r-l CO lO T— 1 OS iH 2 m IN CO 03 lO (N 05 en 00 o o o m a (N 00 CO l> rtl O CO r^ o o 02 Numb ulletin 'hysici. O .-1 rH (N •O CO 7-1 d CO o ^ to o 1-1 ^ T^ CO CO CO 1—1 o 1-1 fflf^ §353 ^ ■ o O O K3 -# o 00 1—1 c 3 >0 * o Tl< r-k \a -1 ^~ lO O to c 3 Oi -° S'S c d ; CO to 00 00 CD T-H ^ CO c n CO 30 >-< CO to t-" lO 1—1 1- h" t£ 3" ^"^ Oi I— 1 1—1 10 ■^ ^^s e •<:& TR ■2 pH o cs u 5 C^ I o 1^ lO 1^ Ttl >o t^ 1- H ^ S-ts S c 3 t£ > ■* CV to l> 00 00 t^ o o 3 1-1 ! Numb Visits 'hysicii c^ 3 T) < .-( (N to CO CO ca to -il < 03 03 00 1^ < ||| c > C o a> CO t-- CO o to f~ 10 ir 3 C H D 42 GENERAL SUMMARY WITH NOTES Table 19. — Putting a Stop to Soil Pollution. Educating the People. Through the Schools Through Public Lectures State Number of Teachers in State Teachers Reached By Visit By Letter By Bulletin or Leaflet No. Lectures Given Est. No. Attend- ing Alabama Arkansas 9,220 10,175 8,714 9,487 6,403 10,166 8,422 4,255 9,233 21,277 9,000 471 2,199 129 384 360 1,646 214 22 483 300 405. 287 335 507 711 1,698 566 1,452 75 168 100 666 620 33,460 50,139 Georgia Kentucky Louisiana Mississippi .... North Carolina. South Carolina. Tennessee Texas Virginia 75 "ii293' 2,615 1,250 1,470 157 1,491 450 340 122 1,593 1,186 4,503 45,520 1,068 1,491 36,663 250,151 58,919 108,062 7,131 17,350 10,709 46,596 52,015 Total 106,352 6,613 9,088 55,823 6,798 671 , 195 Table 20. — Putting a Stop to Soil Pollution.* Educating the People. Through Bulletins Through the Press State Number of Bulletins and Leaflets 94,611. Number of Papers in State Personally Visited Letters Articles to Press Furnished Alabama Arkansas 235 290 311 289 198 234 255' 156 252 933 211 25 139 33 411 53 146 120 66 79 97 38 2 ! 140 ' 207 Georgia Kentucky Louisiana Mississippi. . . . North Carolina. South CaroUna. Tennessee Texas Virginia. ...... 26,605 67,060 80,614 100,294 192,423 82,100 44,742 128,687 67,000 6 38 64 68 1,474 31 61 69 365 79 275 208 161 78 191 110 Total 884,136 3,364 . 1,207 1,807 1,820 •This table includes only the work of the field directors; not that of the central office. GENERAL SUMMARY WITH NOTES 43, o M o o o OS CO o o o «3 »o o 00 o 00 CO o o s ■^-ts > CO r— OS CO o o o 1^ t^ CO ^ o to 00 CO eo" CD OS us" CO CO CO E M CO 4 00 «• •» o w o o o 04 OS o U3 o g OO o CO no o o OS o s o 00 ol CO o CO ■* us g o +e *< lO tN. »o S w CO CO t^ CO OS M eo" o o o o g o o CO p CO o o S o o to cr ■* OS "* r- c . >> '^ '~' ^^ co' '"' ci" «» «» o Csi O o o c^ CO o o o o t>- o CO o o o OS o o o o o us o o s OS o IM o N C4 o CO o (» OS o> o> OS OS OS »-l OS ^ (N ^ '"' •* o ^ ^ ^ eo «• ■•• o o o o OO OO o o o CO o o o lO M (N o o ■* o o « CO o g OS CO lO t~ ■^ o in iC OS o & (M TtH ■* oo_ «• "^ ^ "!>r a* o o o o lO o o o CO >-H s " M •» CO +J 5 > 91 '3 o i u o 3 1 g i '3 < <: o M iA ■is ^ H H > 44 GENERAL SUMMARY WITH NOTES < in >< 3 c<) on o CO 8 o 00 00 lO w e* o o> o> <=> (N Cd o ■._ 00 o_ U3 t- ■'* CM o H f-T ,-h' -ci co" m" «3 t>" n m ,-i e «» o l^ c» o o ^ M OO OS o C3 s ■ fr- i> CO o o OS i-H lO t- O ai GO >a o e» OS ira t- tM O ^ t- >o o o CO 00 r- O co t~ t- OO ■4< N U3 CM CO t- 1 «>» «» o co N o o t- o U3 OS O o to lO CO ■* o OS o C4 in o r- ^ a> O to o lO CO s "* t- o >> N OO M ■* Tjt t- CM ^ Cd M €« •» C» CO ca o o OS u3 O CO ui o CO CO Tf m o ■* ta cq to CO o OO e» CO o» o CD 00 t- CO OS CM CD ^ C4 ^ OS o .-H ca •-H 00 «« M t^ OO o 00 OS o CO o «o »o r- o -# CO o CO •-) to t^ IM o OO OS o CD \a ^ CD CO ^ tn t- CSl OO CM OO OO - -~1 .-T ws 4* «• o CI OO o o CO CO j^ OO ^ o T« O^ o o ■>!(< OO o OS o ■«J< (M ■* s lO o CO >o ,_, Q CO OS o ,_, ^H t- in CO o in OS Oi r- to I>. 40 CO ^ —' '"' Ttt OO ^ eo «. 4* o o tn o t^ CO >n o CO CO o N lO ■* 00 o CO o o OS « U3 00 CO CO ^ >o Oi lO th OS A>» co" >o" O ai • t ^ a OS W .2 .3 1 m i i a i J3 j3 j '3 ■3 s § o o 3 O CO § V *& GENERAL SUMMARY WITH NOTES 45 < o o m IS CO CO r- ■*»* >fa M CO o C4 CSS o t— M OS Oi OS -* ■-1* eai OO eo OS CO *OS CJSrl o TD— i 00 ui ea CO CI CO COCO §5 1^ CO o »o ^ ■*«• e4 CO •1 QO ot- ■^ I?- lO Ui OS 00 '1 C^us '^ co- co CO s s" ss s «" IQ CO lO |¥ s «» •» «• oo OS ■* CO CD OS o s >r> eo CM cot- s OO o OS (M CO •* oo^ 1 eo 00 ^ 00 ^H OO 00 to 1-100 o CX> o oo 00 CO -* OS CO CO (Mt- o O o •o oo ■* CO t^ co_ o t^__ "*- MCD OS H ■* CO OS 3 s" CD >o" s m" -*" OS CD oo s (M ^ s ^ 00 »o ^ ^Os CO oo v-t "3 CO oo OTiO OS CO OS CO CO CO s ^ "* oo Cil eq M o t- oo 00 t- s oo_ »• o CO oo_ C» "*- o_ eo CDiO (N « co' ■-si" -ji" eo" ■«*<" CO* ■*' CO eo" co" csTio oo' ■g" •* «» «» •• ^_, CO eo >o CO S OS lO 00 »o 1K eOcD C4 c W3 -* CO 00 CO CO« OS o o rfl CM OS C4 OS too' CO CO t- o o CO o CD ■I}* °^. tP •>t « o_ CO 00 OS o o_ oo 5 eo' eo" "*' ■* eo" lo" eo' CO "* co" eo" CO-*" oo' ■^n ■* CO OS «» «» «» M lO 00 eo iO oo lo »ooo CO ' (M eo "* o oo o OS iO CO iO o eoos CO U3 •* eo OS OS o t^ ^ o oo eo CD CO o eo CO eo CO ■<»* r- r- OO CO eo -HCO t- OS ■ CO »o CD COCO CO 2 CO s ■*" S' OS oT ■*" co" "* CO •• TlT 00 CO CO o 00 CO IM ^ CO t-b- ^ ^ Oi o CO o CO o o OS CO OS ■<*< oo ION r— o OS o cq eo lom o o> ■* o CO '*>'^- ■<»< o o~ t^" oo" o" ■*' e»oo oo" ■^ —• e>»--H: "* «• «» w Co CO (N 00 OS OS o '-14 OS o ^ ^ CO OS OS (M CSSt^ ^ ^ CO ■-K ■^ o lO -HOO o o> 5 » lO OS_ o_ o_ OI>-_ oo '-*" Tt* co" CO OS ■*" »o" 00 rp^ CD CD «• M «» \ i { 0) iw 3 1 1 1 :| 13 " >i j "p. o o si ■3l d 1 A 2 § •s < 46 ALABAMA. CHAPTER II. SUMMARY OF ACTIVITIES AND RESULTS BY STATES.* ALABAMA. I. INFECTION SURVEY. Infection survey, based on an examination of at least 200 children between the ages of 6 and 18 years, taken at random from the country. County Surveyed by Number Examined Number Infected Per cent, of Infection Autauga Baldwin Chambers Chilton.., .... Clarke Hale Lamar Marengo Mobile Tuscaloosa WaUier Washington Dr. Orr. Dr. Perdue Dr. Orr Dr. Grote Dr. Perdue Dr. CaldweU Dr. Grote Drs. CaldweU and Grote .... Drs. Grote and CaldweU Dr. Orr Drs. Grote and Orr Dr. CaldweU. . . . 430 632 380 982 473 761 431 1,034 1,360 2,745 1,724 1,350 228 454 54 694 367 468 349 606 708 857 391 821 -53.0 71.8 14.2 70.6 77.5 61.5 80.9 58.6 52.0 31.2 22.6 60.8 12,302 5,997 48.7 II. SANITARY SURVEY. Sanitary survey, based on an iaspection of privy conditions at at least 100 ecu ntry homes. Doctor and County Type or Privy Sanitary A B C D U E F Total Index 30 179 56 149 90 60 143 155 29 52 121 97 29 189 96 59 173 93 42 148 155 103 141 208 245 245 149 223 236 198 177 207 224 4.61 Dr. Perdue — ^Baldwin- _, 8.60 2.28 Dr. Grote— Chilton 6.08 Dr. Caldwell — Hale - 6.04 2.24 Drs. CaldweU and Grote — Marengo— 6,05 Drs. Grote and Caldwell— MobUe.... 1 — - — - — - 7.82 1.65 Dr. Grote— Walker 2,61 Dr. Caldwell— Washington 5.40 1 — - — - 14 Total 1,054 1,184 2,253 'All summaries will be found in the tables in chapter I. ALABAMA 47 CO < CO Q Z & O u o Pi o s S-5 S n tDOO-<**OOCOO« cioc- ffl »i H a) ifl t! oSrh'S t*r*ir3 OPnOOpHOOO'^'go'^tg rag . 'T,'*^ OOQOOOQOO OPQ 48 ALABAMA IV. WORK OF LABORATORY. Number specimens examined _... Number specimens showing hookworm infection Number specimens showing Ascaria _ Number specimens showing Hymenolepis.-. Number specimens showing Trichocephalus Number specimens showing Oxyuris--_ .' Number specimens showing Tenia Saginata Number specimens showing infection Number specimens negative Total During 1013 731 223 8 5 18 266 465 V. WORK OF GENERAL PRACTITIONERS OF MEMCINE. (Number of Physicians in State, 2,500) Number of physicians personally visited Number of lectures to physicians Number of circulars or bulletins to physicians Number of letters or post cards to physicians Number physicians reporting treating Uncinariasis - Number of persons reported treated by physicians. . 30S 10 130 3,G2S VI. EDUCATING THE PEOPLE IN SANITATION. (By Field Directors). 1. By Public Lectm-es: 335 Estimated number attending—. _ . 33,460 2. Through the Schools: Number teachers visited . _ _ 471 287 Nnm^**^ paTTiphlftfa anH hiillAtrin'' t" t.Anj>liprq 3. Bulletins, Leaflets and Other Literature: 94,611 Number sanitary-privy leaflets distributed. . _ * • 4. Through the Press: 25 Number letters to editors . _ . . 2 Number articles furnished for publication 140 ARKANSAS 49 ARKANSAS. I. INFECTION SURVEY. Infection survey, baaed on an examination of at least 200 children between the ages of 6 and 18 years, taken at random from the country. County Surveyed by Number Examined Number Infected Per cent, of Infection Clark Conway Faulkner Independence . . Lee Lonoke Dr. Campbell Dr. Campbell Dr. Jacocks.. Dr. Fly 590 612 1,289 336 603 348 736 1,427 391 269 940 101 7 27 64 124 7 421 439 60 17 414 17.1 1.1 2.1 19.0 Dr. Bradford. Dr. Fly 20.56 2.01 Miller St. Francis Sevier White Dr. Campbell Dr. Bradford. Dr. Campbell Dr. Fly 57.2 30.76 15.34 6.3 Woodruff Dr. Bradford. 44.04 Total 7,541 1,681 22.2 II. SANITARY SURVEY. Sanitary survey, based on ar inspection of privy conditions at at least 100 country homes. Type of Pbivy Sanitary Doctor and County A B C D E F Total Index Dr. Campbell — Conway 120 112 159 142 211 231 459 228 293 308 240 375 347 536 309 113 133 486 111 197 360 487 506 678 520 344 592 714 404 ,505 3.33 2.3 2M Dr. Bradford— Lee Dr. Fly— Lonoke 4.05 Dr. Campbell— Miller 6.71 7.75 Dr. Bradford — St. Francis 3.19 7.25 Dr. Fly— White 6.09 Total 2,263 2,847 5,110 50 ARKANSAS < 'A b «! Q H Z & o o O o ill 5 g S .-(«oiocv»oi»HO.-ii«eo'*m Q 1 I s ■a O n 1 .a CD g £ i2 I I 1 i^ I I I I I I I ^ M H M I 1^2; 1 |«"*^N 1 CO 1 i-ioo-*'noo--*,-it^ocoi>o 1 r*oc4rHr~t^o e4^^-Hi^ a ft S 155 96 104 28 152 25 149 72 197 37 121 15 132 04 20 62 130 10 98 54 88 51 110 27 CO 1 Amount of County- Appro- priation SgSSSS§S8SSS ocoooooooooo 3 1 J 1 Campbell— Clark Fly— Cleveland Campbell — Conway Fly-DaUas Jacocks— Faulkner Bradford— Eee Fly — Lonoke Campbell— MiUer Campbell— Ouachita Bradford— St. Francis Campbell— Sevier. _ Bradford- Woodruff & ARKANSAS 51 IV. WORK OF LABORATORY. Number specimens Number specimens Number specimens Number specimens Number specimens Number specimens Number specimens Other Parasites Number specimens Number specimens examined.- showing hookworm infection, showing Ascaris showing Hjj^menolepis showing Trichocephalus showing Oxyuris showing Tenia Saginata showing infection-, negative Total During 1913 446 73 11 11 112 334 V. WORK OF GENERAL PRACTITIONERS OF MEDICINE. (Number of Physicians in State, 3,600) Number of physicians personally visited.. Number of lectures to physicians _ Number of circulars or bulletins to physicians f Number of letters or post cards to physicians \ Number physicians reporting treating Uncinariasis Number of persons reported treated by physicians 462 55 7,022 1,500 VI. EDUCATING THE PEOPLE IN SANITATION. (By Field Directors). 1. By Public Lectures: Number public lectures delivered _ _ 507 Estimated number attending.. . _ 50 139 2. Through the Schools: 2,199 Number letters to teachers.. . . Number pamphlets and bulletins to teachers. . 3. Through the Press: Niirnhfir papftrs pfirRnnRlly visit.RH 139 207 52 GEORGIA GEORGIA. I. INFECTION SURVEY. Infection survey, based on an examination of at least 200 children between the ages of 6 and 18 years, taken at random from the country. County Surveyed by Number Examined Number Infected Per cent, of Infection Ben Hill Bulloch Burke HaU Hancock Irwin Jefferson Jenkins Liberty Rabim Screven Stephens ?/ayne Wilcox Wilkes Dr. Henry Dr. Dobbs. ...'.. Dr. Wood Dr. Vemer Dr. Wood Dr. Henry Dr. Wood Dr. Wood Dr. Abercrombie Dr. Abercrombie Dr. Henry Dr. Vemer Dr. Abercrombie Dr. Wood Dr. Wood Total 488 376 369 573 373 303 288 422 266 445 796 209 692 213 270 385 344 357 407 151 292 262 400 239 254 771 156 555 143 128 78. 91.4 96.74 70.9 40.48 96.3 90.9 94.78 89.94 57.0 96.0 74.6 80.2 67.13 47.4 6,083 4,844 79.6 II. SANITARY SURVEY. Sanitary survey, based on an inspection of privy conditions at at least 100 country homes. Type of Phivy Sanitary A B c D E F Total Index Dr. Henry — ^Ben Hill _ 192 249 96 190 167 159 195 199 163 201 181 115 188 135 84 513 242 122 405 83 183 [17 60 138 50 7 "239 88 13 54 98 65 85 22 ""ei" 134 115 57 5 23 124 209 309 234 240 174 398 283 212 217 299 236 200 210 135 145 647 357 179 410 106 307 9.13 Dr. Dobbs — Bulloch 8.05 Dr. Wood—Burke * 4.1 Dr. Abercrojmbie — Clinch 7.9 Dr. Henry — Dooly, - __ 9.6 •Dr. Verner— HaU 3.99 Dr. Wood— Hancock 6.89 Dr. Henry — ^Irwin.._ 9.4 Dr. Dobbs— *Jackson.. 7.5 Dr. Wood— Jefferson 6.72 Dr. WooH^.Tfinkinfl 7.6 5.75 Dr. Abercrombie — -Liberty 8.95 10. 5.79 Dr. Henry — Screven . . 7.9 6.77 Dr. Wood — Warren 6.8 Dr. Abercrombie — Wayne 9.87 7.83 Dr. Wood— Wilkes— S.96 Total 4,062 1,445 5,507 •Re-survey 1913. GEORGIA 53 aoocoo>oc9^Hooooo OS Oi oo eo OS CO . Tj< CO ^ t^ 10 CO o o '-' r~ OS r- -H Tt< OS >o O O iQ ^H CQ 00 ■»* -^ iC -^ 00 O Tji CO o r- CO t- .-((M »-C M CO ^H CO CD to M i-t CO OO 1-1 CD t« O 1-1 ^ CO CO CO ■^ i-i O OS 10 -«cgTtncoc*i CDr-(« "■*"3CO u^S^-^Hcq^-l,-lC£ :3-tHOOO-*co CD oeom-^oooio icotDCDC4>-i M m N CO C4 1* it.ftH 21,370 Number sanitary-privy leaflets distributed 1,435 3,800 4. Through the Press: 33 Number articles furnished for publication 6 VII. NOTES ON WORK OF THE YEAR. 1. The State Board of Education, in classifying its schools, requires under the heading "Standard County School" that two sanitary privies be provided. Up to this time thirty-nine schools have qualified as "stand- ards." 2. Every physician in Georgia, and 143 senior medical students, have been provided with charts on soil pollution and hookworm disease. 3. Definite instruction on hookworm disease is given by the two Georgia medical colleges in grade "A". 4. Hookworm disease has been eradicated from JekyU's Island. 5. The State Board of Education adopted Ritchie's "Primer of Sanitation'' and Hutchinson's Health Series for use in the public schools of Georgia during the next five years. KENTUCKY KENTUCKY. 55 L INFECTION SURVEY. Infection survey, based on an examination of at least 200 children between the ages of 6 and 18 years, taken at random from the coun try. County Surveyed by Number Examined Number Infected Per cent, of Infection Christian Clark Dr. Richmond.. . Dr. Shirley Dr. Lock Dr. Shirley Dr. Richmond... Dr. Lock: Dr. Steele Dr. Steele Drs. Lock and Shirley Dr. Steele Dr. Lock Dr. Shirley Dr. Lock Dr. Steele Dr. Lock Dr. Richmcnd. . Dr. Lock 1,173 3,024 5,477 2,022 4,852 9,340 3,364 5,250 3,981 8,009 3,747 2,830 9,503 518 9,177 1,404 7,919 551 22 263 2,279 39 469 3,956 2,149 2,504 745 1,608 803 .1,524 3,960 24 2,912 20 3,052 42 1.9 8 7 Harlan Harrison Jefferson Laurel 41.6 1.9 9.6 42.0 63 8 McCreary. .... Madison Pulaski Rockcastle Rowan Whitley Franklin Bell Hickman Knox Warren 47.7 18.7 20.0 21.4 53.8 40.1 4.6 31.7 1.4 38.5 7 6 82,141 26,371 32.1 II. SANITARY SURVEY. Sanitary survey, based on an inspection of privy conditions at at least 100 countrv homes. Doctor and County Type of Privy A 3 B C D 7 45 "'73 7 1 41 E F Total Index 120 1,297 16 587 132 52 521 207 273 59 811 61 424 288 ""200" 191 496 15 736 261 288 388 303 263 91 621 405 2,079 231 '"247' "534" 124 145 2,078 278 1,032 528 356 837 298 901 469 2,892 292 705 330 615 415 725 785 11.5 Dr. Shirley— Clark 6.7 Dr. Lock— Harlan— 075 Dr. Shirley— Harrison 44 39 14.6 2.92 Dr. Steele— Leslie 1,53 Dr. Steele— McCreary 1 11 7.74 Dr. Shirley— Madison 6 94 Dr Steele— Pulaski . 6 5 2 3 25 Dr. Lock — Eockcastle 1 52 2.82 Dr. Lock— Whitley 2 08 Dr. Richmond — Ballard 40 10 3 241 32 365 215 17 3 Dr. Richmond — Fulton 12 6 Dr Richmond — ^Union 15 OS 17.77 Dr. Look— Clay 1 3 40 108 125 1165 12 8 47 40 Total 5,735 6,586 13,681 56 KENTUCKY < CO «3 H O O o o h| 1 27 2,138 44 9 76 1,987 1,804 2,380 415 1,406 806 1,438 1,099 m" 1 K H i 1 K H 1 1 i I 1 i2 H i J3'~ i ;gs-°" i'"°'S s O 27 2,096 37 9 76 1,945 1,788 2,379 413 1,406 806 1,436 1,074 3 eo ■|1 .£3 U a« I 1,173 4,957 2,022 1,554 490 9,340 2,606 6,250 3.381 8,009 3,747 2,419 5,488 i" 1 1,161 2,861 1,983 1,417 415 5,384 818 2,746 2,853 6,401 2,944 983 3.269 S3 1 22 2,096 39 137 75 3,956 1,788 2,504 528 1,608 803 1,436 2,219 ggggggoooogoo Amount of County Appro- pnation ggggggggggggo lllllllllllll s o R 3 (■ OS R Christian— Eichmond Harlan— Lock Harrison — Shiiley Clark-Shirley Jeff erson— Eichmond Laurel— Lock Leslie— Steele McCreary— Steele Madison — Lock& Shirley. Pulaski— Steele Rockcaatlo— Lock ■Rowan — Shirley Whitley— Lock S KENTUCKY 57 IV. WORK OF LABORATORY. Number specimens examined Number specimens showing hookworm infection. Number specimens showing Ascaris ., Number specimens showing Hymenolepis Number specimens showing Trichocephalus Number specimens showing Oxyuris Number specimens showing Tenia Saginata Number specimens showing infection Number specimens negative „_ Total During 1913 26,078 7,264 7,958 535 2,897 96 5 11,441 14,637 V. WORK OF GENERAL PRACTITIONERS OF MEDICINE. (Number of Physicians in State, 3,340) Number of physicians personally visited Number of lectures to physicians Number of circulars or bulletins to physicians Number of letters or post cards to physicians Number physicians reported treated Uncinariasis Number of persons reported treated by physicians 5,227 75 32,139 16,610 314 29,720 VI. EDUCATING THE PEOPLE IN SANITATION. (By Field Directors). 1. By Public Lectures: Nnrnhftr piihllR Ipfitiirp^ Hftlivfirerl 1,698 250,151 2. Through the Schools: 334 Number letters to teachers 122 3. By Bulletins, Leaflets and Other Literature: 67,060 4. Through the Press: 411 38 Number articles furnished for pubUcation 365 LOUISIANA. I. INFECTION SURVEY. Infection survey, based on an examination of at least 200 children between the ages of 6 and 18 years, taken at random from the country. Parish Avoyelles. Bossier. . . Jackson Re 1 River Sabine Allen Ascension Beauregard . . . . Calcasieu Caldwell East Baton Rouge East Feliciana.. Grant Iberville LaSalle Natchitoches. . . Ouachita Point Coupee . . West Feliciana. Surveyed by Dr. Adams Drs.Baucum and Trezevant . . Dr. Trezevant. Dr. Baucum . . Dr. McKinney Dr. McKinney Dr. Adams. . . Dr. McKinney Dr. McKinney Dr. Trezevant. Dr. Adams. . Dr. Adams. . Dr. Baucum. Dr. Adams. . Dr. Baucum. Dr. Baucum. Dr. Wright.. Dr. Adams. . Dr. Adams. . Total. Number Number Per cent, of Examined Infected Infection 785 52 6.6 1,152 414 35.9 2,838 2,267 79.8 524 234 44.6 2,502 1,208 48.2 1,480 757 51.1 376 40 10.6 3,100 1,866 60.2 1,414 463 32.7 2,625 1,310 49.9 1,054 209 19.8 750 159 21.2 2,038 1,222 59.9 243 1,357 704 51.8 1,194 647 54.1 703 493 70.1 219 3 1.3 ■ 417 8 1.9 24,771 12,056 48.9 II. SANITARY SURVEY. Sanitary survey, based on an inspection of privy conditions at at least 100 country homes. Type DP Pbivt Doctor and Parish A B C D 195 .... E F Total Index 210 162 108 71 39 160 177 275 200 321 167 91 244 33 133 215 181 170 153 5 178 455 134 422 140 10 173 31 582 63 133 21 176 118 317 40 ""'ef 410 340 564 205 461 305 291 448 244 904 292 224 368 214 251 638 290 211 253 17.0 Drs.Baucum and Trezevant — Bossier Dr. Trezevant — Jackson . — - .... .... 4.7 1 9 3.4 Dr. McKinney — Sabine _ .8 Dr. McKinney — Allen ■ 5 87 6.41 2 15 16.6 Dr MnKinnRy — Rpaiirp^.rd 6.1 Dr. MnKinTip.y — Oalnji.qieii 13 1 56 9.5 Dr. Trezevant— Caldwell , 3.55 Dr. Adams — ^East Baton Rouge Dr. Baucum — Grant .... .... 6 11.3 4.0 2 21 80 15.3 Dr. Baucum — LaSalle 1.7 5.29 Dr. Wright— Ouachita- 6 57 41 39 581 4.2 Dr. Adams — ^Point Coupee 4 .... 8 13.8 12.9 Dr. Adams — West Feliciana . 9.9 i 4 50 Total 3,115 3,059 6,813 LOUISIANA 59 < ;=> o o § O II 5 a 1,030 40 61 2,599 691 1,389 1,311 143 1,702 2;267 1,075 6 374 1,765 1 8 200 913 916 «o" K s H o s o & a § 1 .a CQ CD > iS 1 1 j iM . ica 1^ 1 1OT |c^ < 1 1 icq . (M lU £ □0 > IOOU3COC4 1^ icocq IC4 1 i lOOif^ »0 i^iONCOOtDt^ ir-MCOWt^ 1 Icob-o 03 oo_ co" o 767 40 50 1,814 414 463 1,197 137 1,250 "i;954" 647 3 234 1,208 1 8 169 820 691 ■1. I? 1,480 376 785 3,100 1,152 1,414 2,626 701 2,038 243 2,838 1,194 219 624 2,602 188 417 760 703 1,357 to i 723 336 733 1,234 .738 961 1,315 564 816 243 571 647 216 290 1,294 187 409 691 210 653 1 757 40 52 1,866 414 463 1,310 137 1,222 "2;267' 647 3 234 1,208 1 8 159 493 704 1 II S 200 00 32 00 42 00 275 00 250 00 200 00 271 00 34 10 160 00 17 00 200 00 200 00 35 00 200 00 200 00 21 30 60 00 100 00 200 00 150 00 Amount of Parish Appro- priation oocsooooooooooooooooo oooooooooooooooooooo OOOiOOOi-HOOOOOOOOOOOOO 000^-u^O^-OU20000000000»0 W9 s CO 1 Porter— Allen Adams — ^Ascension . _ Adams— Avoyelles _•_ McKinney — Beauregard- _ Baucum — Bossier Porter-Calcasieu Trezevant— Caldwell Adams— E. Baton Rouge. Baucum — Grant Adams — Iberville Trezevant — ^Jackson Baucum — Natchitoches.. _ Adams — Point Coupee Baucum — Red River McK inney— Sabine- Adams— W. Baton Rouge. Adams — W. Feliciana Adams — E, Feliciana Wright— Ouachita .-- Baucum — La Salle 'efl 60 LOUISIANA IV. WORK OF LABORATORY. Number specimens examined— Number specimens showing hookworm infection- Number specimens showing Ascaris ., Number specimens showing Hymenolepis Number specimens showing Trichocephalus Number specimens showing Oxyuris Number specimens showing Tenia Saginata,----. Number specimens showing infection.. J Number specimens negative Total During 1913 1,862 418 631 1,231 V. WORK OF GENERAL PRACTITIONERS OF MEDICINE. (Number of Physicians in State, 2,039) Number of physicians personally visited Number of lectures to physicians. Number of circulars or bulletins to physicians Number of letters or post cards to physicians.. Number physicians reporting treating Uncinariasis Number of persons reported treated by physicians VI. EDUCATING THE PEOPLE IN SANITATION (By Field Directors). 5,275- 7,850 185 5,011 1. By Public Lectures: ^ 566 ~ 58,919 2. Through the Schools: 360 1,293 1,593 3. By Bulletins, Leaflets and Other Literature: 44,272 8,899 27,443 4. Through the Press: 53 64 Number articles furnished for publication 79 VII. NOTES ON WORK OF QUARTER. 1. Reports show that 1,606 sanitary privies were built in the rural com- munities of Louisiana during 1913. 2. Mr. W. N. Meyer, Superintendent, Camp Curtis, Calcasieu p^ish, offered to his employes one month's house rent free for the person who had the cleanest premises, the field director of the sanitary commission to act as Judge. 3. The work has been endorsed and recommended to other parishes by the pohce jury and school board in practically every parish in which the campaign has been conducted. 4. The superintendents of education in the twenty-two parishes report- ing, have stated that 272 closets were built during the year 1913, twenty- four of which were water-flush and 216 Stiles's sanitary closets. MISSISSIPPI 61 MISSISSIPPI. I. INFECTION SURVEY. Infection survey, based on an examination of at least 200 children between the ages of 6 and 18 years, taken at random from the country. County Surveyed by Number Examined Number Infected Per cent, of Infection Smith Rankin Chickasaw. . . Carroll Webster Montgomery. Lauderdale . . Grenada Hinds Leflore Madison .... Copiah Noxubee .... Newton Lawrence *Marion Kemper Oktibbeha. . . Jefferson .... Claiborne Calhoun Holmes Adams Lowndes .... Prentiss Lee Clay Dr. Whitfield Dr. Whitfield Dr. Whitfield Dr. Whitfield Dr. Whitfield Dr. Whitfield Dr. Howard Dr. Howard Dr. Howard Dr. Howard Dr. Howard Dr. Buchanan Dr. Buchanan Dr. Buchanan Dr. Buchanan Dr. Buchanan Dr. Gill Dr. Gill Dr. Dedwylder. . . . Dr. Dedwylder. . . . Dr. Dedwylder. . . . Dr. Dedwylder. . . . Dr. Dedwylder. . . . Drs. Gill & BosweU Dr. Boswell Dr. Boswell Dr. BosweU Total 1,795 1,348 1,003 1,562 1,608 1,276 2,157 1,547 393 1,251 1,934 1,832 2,181 2,547 1,753 3,140 1,184 1,063 1,071 847 1,458 519 804 775 2,562 1,320 1,098 1,556 725 149 20 240 188 1,211 18 14 6 51 970 122 1,456 1,091 2,490 815 231 158 4 149 27 5 161 1,336 142 21 86.6 53.7 14.8 ,.01 14.9 14.7 56.1 .01 .03 .004 .02 52.9 .05 57.1 62.2 79.02 68.8 21.7 14.7 .004 10.2 .05 .006 20.7 52.1 10.7 .01 I 40,028 13,356 33.3 *Indicates second survey. 62 MISSISSIPPI II. SANITARY SURVEY. Sanitary survey, based on an inspection of privy conditions at at least 100 country tiomes. Type of Privy Sanitary Doctor and County A B C D 2 E F Total Index 766 159 345 316 230 44 163 53 16 529 486 . 654 304 446 580 212 785 905 122 158 141 304 32 298 266 16 472 215 71 148 83 663 400 325 286 132 169 219 249 92 ""m 219 "i;327 619 1,057 886 687 451 388 278 262 235 252 271 1,235 65 166 166 51 1,431 559 670 603 414 213 382 302 108 629 497 827 623 446 1,952 831 1,842 1,846 709 609 529 582 294 533 518 287 1,722 280 237 324 146 •5.3 2.8 Dr. Howftrrl — Htrris 5.1 1 1 -— ---- 5.3 Dr. Howard — Madison Dr. Whitfield— Rankin Dr. Whitfield— Chickasaw— Dr. Whitfield— Carroll 1 5.9 2.06 4.2 1.7 Dr. Whitfield— Webster 1.4 10. Dr. Buchanan — Noxubee. Dr. Buchanan — ^Newton Dr. Buchanan — Lawrence .... .... 11 10.3 7.9 6.S 10. Dr. Dedwylder — Jefferson Dr. Dedwylder— Claiborne Dr. Dedwylder— Calhoun.. .... 30 15 3.93 2.5 4.3 55 .... 6.4 Dr. Dedwylder — ^Adams 1.7 Dr. Gill— Kemper . 2.5 Dr. Gill— Oktibbeha 2.6 Dr Gill — T^wnH<«^ 5.2 Dr. Boswell — Prentiss 1.0 Dr. Boswell- Lee 5.5 Dr. Boswell— Clay. __ 5.1 Dr. Boswell— Benton.. .6 15 100 "io' 12 50 3.2 Dr. Buchanan — Washington Dr. Buchanan — ^Neshoba Dr. Dedwylder — Harrison Dr. Dedwylder— George 1 2 7.6 2.9 5.3 7.7 Total 9,326 11,326 20,805 'Indicates second survey. MISSISSIPP[ 63 (M00-IOSt^O<0 .-li-l t^lOTtfi-HCO i-ieoxnt* t^ CO oo 1— 1 OS w Tjt CO o c» eo lo CO o tooii-Hi-i osoooj'-HmOT-i'O'— I'O'-i^T-ico .._ , , Oc^ooo ■© csi CO ira N »o CO CO i:^ O CO o CO 00 -rjio cj 1-1 ^ CO cq ^ 1- •acO'-iMcoNco'^N -i*^ f ^tOOSt- Tt< kO O O kO CO >0 CO CO CO CO <-( tK CO r»t-.-(t^ 1-1 OS OS M >ra CO oo CO OS 1-1 lo OS 00 -^ OOCOOOtH lO CO 05 i o CO t— ioooi-ieo Ocoeooo cal-lto«D^ _ . iracOCSOs «D^-iC^03C0»0 COCOi-"!-! 1-t CO -H CO i-i CO -^ CO >n O OS «D CO .-I T-i CO CD -^ OO CO .-I lti.l i-HOOO oooooooooooooo Doooo oooooooooooooo C3000 O t-lOOOOOOOiOOOOiO loiooo ^ I— I oo o irao o o^H oo eo^H COdCOCO CO CO CO CO Cfl CO CO CO C^ CO CO CO CO CO OOOOSOOIO ooo-*ooco Cfl CO CO M CO CI .-I • cU J P ■t; a cjj fl' ^^$ 'O ta ' Ij3 S 1=1 a I I I I J, d a a a ^^^^^^ 9 S 3 9 S & fc ft £::3j3j3jajq d^ T S^m a Ej< a ll 1.3 o fl ! a >,'( PflQO no I I ssjs '22 I I I 2 ■J^J to m in ^ « o S So « OQWMpqQ IV. WORK OF LABORATORY Number apecimens examined. _ Number specimens showing hookworm infection- Number specimens showing Ascaris Number specimens showing Hymenolepia __. Number specimens showing Trichocephalus- Number specimens showing Oxyuris __ Number specimens showing Tenia Saginata Number specimens showing infection. Number specimens negative. Total During 1913 664 23 5 697 1.9 V. WORK OF GENERAL PRACTITIONERS OF MEDICINE. (Number of Physicians in State, 1,783) Number of physicians personally visited _ _ Number of lectures to physicians __ Number of circulars or bulletins to physicians Number of letters or post cards to physicians Number physicians reporting treating Uncinariasis Number of persons reported treated by physicians- VI. EDUCATING THE PEOPLE IN SANITATION, (By Field Directors). 677 3 1,042 815 592 5,614 1. By Public Lectures: Number public lectures delivered.. Estimated number attending 2. Through the Schools: Number teachers visited Number letters to teachers Number pamphlets and bulletins to teachers 3. By Bulletins, Leaflets and Other Literature Number bulletins and leaflets distributed Number sanitary-privy leaflets distributed Number other literature distributed. 4. Through the Press: Number papers personally visited Number letters to editors Number articles furnished for publication 1,452 108,062 1,646 2,615 1,186 54,481 21,007 24,806 146 68 275 VII. NOTES ON WORK OF THE YEAR. 1. The results obtained in Mississippi during 1913 greatly exceed those obtained during any previous year since the organization of the work. 2. The number of treatments are les,^, however, due to the fact that the campaign has been conducted in lightly infected counties. 3. It is most remarkable that the response for examination for hookworm disease has been even greater than during the two preceding years, although the work was done prev- ious to 1913 in the heavily infected counties. This shows that the people have been edu- cated concerning public health work to a considerable extent. It is not nearly, so difficult now as at the outset to obtain the co-operation of the public in this work. 4. Much emphasis has been placed on lecturing to the colored schools during the present ypar. 5. The salaries of uounty health officers have been increased in many counties during the present year. 6. There has been a marked improvement in the sanitary condition of the towns and cities of the State. 7. The Bureau of Vital Statistics has been splendidly organized and the results obtained during the past year are most encouraging. 8. The work of the laboratory has greatly increased during the year 1913, and it is now upon a thoroughly organized basis. 9. The women's clubs have given much more active support to health work than per- haps during any corresponding period in the history of the State. These clubs can be and are being used most effectively in improving the sanitary environment of the com- munities and towns of the State. 10. The sanitary conditions of the homes and schools of the State is steadily improving. _ 11. During the present year a conference was held for the benefit of county and muni- cipal health officers, and there were present from seventy-nine counties of the State sixty- five county health officers. The meeting was pronounced successful from every point of view. 12. During the State Fair the State Board of Health prepared a large health exhibit, which was seen by at least 25,000 people. NORTH CAROLINA NORTH CAROLINA. 65 I. INFECTION SURVEY. Infection survey, based on an examination of at least 200 children between the ages of 6 and 18 years, taken at random from the country. County Alamance . . . Alexander . . . Alleghany . . . Avery Cabarrus .... Camden Caswell Cherokee. . . . Clay. Currituck.. . . Dare Durham Forsyth Guilford Haywood. . . . Hoke Hyde Jackson Macon Madison. . . . Mecklenburg. Moore Pamlico Pasquotank. . Perquimans. . Person Polk Rockingham. Swain Transylvania Tyrrell Union Vance Washington. . 'Scotland.. . . *Watauga. . . Surveyed by Dr. Washburn .... Dr. Jacocks Dr. Sloan Dr. Jacocks Dr. Jacocks Dr. Leonard Dr. Washburn .... Dr. Absher Dr. Collinson Dr. Leonard Dr. Jacocks Dr. Sloan Dr. Sloan Dr. Jones Dr. Washburn .... Dr. Hughes Dr. Pridgen. Dr. Absher Dr. Absher Dr. ColUnson Drs. Covington and Jacocks Dr. Hughes Dr. Strosnider .... Dr. Jacocks Dr. Leonard Dr. Sloan Dr. Covington .... Dr. Sloan Dr. Washburn .... Dr. Covington .... Dr. Pridgen Dr. Covington .... Dr. Sloan Dr. Pridgen Dr. Hughes Dr. Jacocks Total . Number Examined 1,126 1,891 617 1,533 1,476 664 627 1,050 669 1,526 1,025 297 665 524 1,680 585 749 1,202 1,614 847 2,695 1,270 829 978 895 644 1,370 1,235 1,652 561 877 3,452 5^8 888 231 338 Number Infected 38,820 224 1,290 10 62 47 240 84 737 301 543 335 120 269 90 170 365 280 774 1,212 liO 324 671 522 102 163 245 1,065 666 842 175 468 90 206 528 Per cent, of Infection 13,434 19.9 68.2 1.6 4.05 3.1 36.1 13.3 70.1 44.9 35.5 32.6 40.4 40.4 17.1 10.1 62.3 37.3 64.3 75.0 12.9 12.0 52.7 62.8 10.4 18-2 38.0 77.7 53.9 50.9 31.1 53.3 2.6 38.2 59.4 38.5 2.0 34.5 *Surveys made in 1912, but complete work not reported. 66 NORTH CAROLINA II. SANITARY SURVEY. Sanitary survey, based on an inspection of privy conditions at at least 100 country homes. Doctor and County Type OF Pbivy Sanitary A 7 B C 1 D 39 E r' Total Index Dr. Washburn — Alamance 281 46 29 62 82 115 127 93 ■ 110 206 112 96 106 274 111 206 100 110 264 348 77 39 182 140 144 48 134 76 119 102 160 88 280 170 160 116 199 173 21 101 235 485 95 220 45 87 110 169 534 281 255 407 226 168 194 171 39 191 184 190 129 162 166 225 93 286 498 206 145 261 256 136 262 330 595 302 332 146 201 415 280 740 386 367 671 575 245 233 353 179 335 232 325 214 281 270 375 181 566 9.1 2.2 Dr. Sloan — ^Alleghany . _ . - 2.0 2.3 Dr. Jacocks — Cabarrus 1 .... .... .... 3.6 8.4 Dr. Washburn— Caswell 1 .... 4 • 2 29 8.7 3.1 Dr. Collinson — Clay - 1.8 1 6.9 3.3 Dr S oan — Durham Dr. Sloan — Forsyth - 3 2 2 6 31 8.9 7.0 8.4 3.9 Dr. Pridgen — Hyde . _ 2.7 Dr. Absher — Jackson Dr. Absher — Macon I 3 2 — - 3.4 3.2 Dr. Collinson — Madison. 3.9 Drs. Covington and Jacocks— Meck- lenbiu-g 6.0 3.1 Dr. Rt.rrtsnidftr — Pfl.iTiiipo 1.67 5.15 7.8 Dr. Sloan — ^Person 4.3 Dr. Covington— Polk. 2.06 1 9 4.2 Dr. Washburn — Swain 4.6 Dr. Covington — Transylvania 4.2 Dr. Pridgen— TyrreU Dr. Covington — Union. ... .... .... 1 4.2 4.0 Dr. Sloan — ^Vance . 4 8 4.94 17 1 12 119 Total . . 4,457 6,287 10,893 NORTH CAROLINA 67 H t- oa tJI lO <-H -ij-i-^oOT-iaiT- n(N<-'t— TtHioMc^ CO > i»nco !D CO "-I cj OS cq »f5 l>--li-HroOSCD(M00'-l»-<-*'*^Hr^^o>coi-<-i jjcor-ooa 11 s-a an uio>«oeoQoe-iir-(Neaooooacn--aicc^ oooc»c.lO^*DCq»OCflCDO>eOlOO»Tt<.-liOT- i-a-^OTjiiofNoeococo-^i-ico^Heooin— ^ lOdeomososoWi-HoooOTjii-itooooeSM eoiot^oc«oot-»oosoo^oo^iooociio»o -lC-Hi-l.-l>-Hi-ICOCOi-li-l>-lt-r- N d «0 go ^ O Cfl CO O "3 "-H CO CO eo OS in O 00 CO OS (M M _, COt^^H t^fS)OSC^-HOOTt»coTjio^ oxj( DO ■>*!<: _ -. oo i-H CO c*i c, -^ ^. - . » - -^ _ .-^ _ . - ^ ■*eococqoo>-HoiTttt-cocoosiMcO'-t'#0'- ■*cocooococooooocococ^a>oioiO'#'-itcoooco r-i3cooocj-^j-n«c3>-^oacocDOcooioooo® como^Hcoco(MOieooiz; eooco^How^oioo^ooooeooot-cQcr-osoOToo ■^■^J^o^noslO^Ol0 1-l^nco^-t^^oc^lOc^3H CKN eq « CQ •-> cq i-i i-i --H .-( i-( i-i 1-1 cq eq rH .-I c^ th 1-1 tj< i-i cq cq i-n i-i r-i ^h cq cq ,-i ,-i .-n r-i co cq i-< q loll Oi-tOOOOOOOOOOOOOOOOOOOO »0OOO»0i0O"3OOOOOOi0»0i0OC3OOO Mca'-icsicqcOOOOO0iOOffi OOo»moooira--Hmmooocqino'"^ g 2 PI £ a> ^ s d ffi »>• 3 c3 P «9 l9li ■t i git 3 J. i1 ! \.x Mii Bji s s a 5ll ^'^W>^ 5 5.2 L j3 S ffi, s i-o-a .I'S o coooos'-t--i^^oooa» 10,-(OCON>0»-((M-(J< m e«3 CO eo F- t^ ^ OS CO ■^eOOieor-NM'-iOi^ OOIM=D»OeO>0-HC5COt» (M lOCC t^ MW C»-^JHt^O)00 CniMO-^00-H0>t^N"3 cqTt-»nr^>nas ■--l^-co^ --i^HOOC^OscaTtiiot^eo Of* »n ^H 1— I ITS 1— I CO W3 Oeocococo-^03r--»- ooeoeqi>-ascooooeD<-H i-iWh-iracsi^i-'(Mt^co >jH i-<«oco oii-icqco OOOOOOOOC3 s ! 2£fe. 0* :9JjE I I ss^fi SOUTH CAROLINA 71 IV. WORK OF LABORATORY. Number specimens examined Number specimens showing hookworm infection. Number specimens showing Ascaris Number specimens showing Hymenolepis Number specimens allowing Trichocephalus Number specimens showing Oxyuris Number specimens showing Tenia Saginata Number specimens showing infection Number specimens negative Total During 1913 1,213 81 216 1 1,514 6,585 V. WORK OF GENERAL PRACTITIONERS OF MEDICINE. (Number cf Physicians in State, 1,303) Number of physicians personally visited Number of lectures to physicians Number of circulars or bulietina to physicians Number of letters or post cards to physicians.. _ Number physicians reporting treating Uncinariasis . Number of persons reported treated by. physicians. . VI. EDUCATING THE PEOPLE IN SANITATION. (By Field Directors).' 12,339 150 1. By Public Lectures: Number public lectures deUvered Estimated number attending 2. Through the Schools: Number teachers visited Number letters to teachers Humber pamphlets and bulletins to teachers 3. By Bulletins, Leaflets and Other Literature; Number bulletins and leaflets distributed — Number sanitary-privy leaflets distributed Number other literature distributed 4. Through the Press : Number papers personally visited Number letters to editors Num.ber articles furnished for pubhcation , 17,350 22 1,470 45,520 20,600 9,200 52,300 31 161 72 TENNESSEE TENNESSEE. I. INFECTION SURVEY. Infection survey, based on an examination of at least 200 children between the ages of 6 and 18 years, taken at random from the country. County Surveyed by Number Examined Number Infected Per cent, of Infection Anderson. ..... Blount Bradley Campbell Cocke Greene Hickman Montgomery. . . Obion Rhea Roane Robertson Smith Dr. Townsend. . . Dr. Lee Dr. Lee Dr. Townsend.. . Dr. Robinson . . . Dr. Yancey Dr. Robinson . . . Dr. Yancey Dr. Robinson . . . Dr. Lee Dr. Lee Dr. Yancey Dr. Robinson . . , Total 439 1,227 764 1,041 1,401 200 200 395 202 528 1,470 223 200 188 806 217 555 800 78 10 14 1 269 737 2 56 . 42.8 65.6 28.4 53.3 57.1 ^ 39.0 5.0 3.5 .49 50.9 50.1 .09 28.0 8,290 3,733 45.0 II. SANITARY SURVEY. Sanitary survey, based on an inspection of privy conditions at at least 100 country homes. Type 3F PbIVT Sanitary Doctor and County A B c D E F Total Index Dr. Townsend — Anderson 90 162 107 111 60 65 118 42 30 31 34 20 78 247 146 94 98 58 71 120 132 97 92 139 42 126 158 169 36 326 280 151 651 104 103 105 248 94 210 294 209 203 200 107 251 200 200 100 360 300 235 898 251 200 206 306 200 4.23 Dr. Lee— Blount _„. Dr. Lee— Bradley . — - — - — , '"s" 6.5 6.7 Dr. Townsend — Campbell 5.4 Dr. Robinson — Cocke. 1 3.1 6.0 7 5.4 Dr. Robinson — Hawkins 2.1 1 '25' 1.76 Dr. Yancey — Knox _ Dr. Robinson — Lewis 8 — - 17.36 .94 .66 6 3.9 Dr. Robinson — Obion 2.7 1 3 3 5.9 Dr. Lee — Roane. . 6.0 5.12 1.8 Dr. Yancey — Washington 3 4 32 83 8.3 8 Total ^ 1,662 3,173 4,930 TENNESSEE 73 z Oh «1 H O O b O o • (O OS oo 1-1 eq CO so IN eoOi—T-i OJ-^tfiOCO CO t~oooo^cOi-'eo>o uat-^t^ o — . ' no lO t^OS ^|l co" i-Tcq" i-T kO 1 < 1 >-4< > > J I I^ I « .a to p t4 1 1 1 it~ 1— ( 1 . iCO > .-1 lOO ■ o 5 ■ H g « « S H 5 I-*.0 iM 1^"* 1 ..^t . 00 !■* 1 « H i-H jcO 1 1 iM ■ .-J« 1 CO ^ & s rti CO .-H iO> lO i(M r* ^ H o» PU o CO o OOWlinoOiO -I^-* OOM^CX) S 2 (M K fc CO H fH -H I lO S 2 Occeoooscoooo OO CJHO Tt4COU3CO m IB 00 1^ ■» io o> .-H cn »o MtjHooin o a (Mioeot*e» •* CC0 lO M CO O M «0 CSI CO CO t^ 00 o^og CO 13 iracsioo ■* ■g i:^ CD OS CO CO b'-§ H .-TeOi-rfNIM" ^"^~ '"' CO .-t S5 »nor*'*jH'-t loco 0»0) 00 CO ■*00i«O OS - C» W3 CO CJUD . COCD-^-CO tr- gd I^-^W*-* ii-ccD l^-KOM lOCD-tlHCO OS lOflOi-Ht— OS lOGO C<1U5>-I OS lO OS OS OS Cqi-( y-* ■<-> ■* ^tf3 ■^ >^P^>H 74 TENNESSEE IV. WORK OF LABORATORY. Number specimens examined. _■ Number specimens showing hookworm infection. Number specimens showing Ascaris Number specimens showing Hymenolepis Number specimens showing Trichocephalus Number specimens showing Oxyuris Number specimens showing Tenia Saginata Number specimens showing infection Number specimens negative Total During 1913 725 73 110 18 35 5 4 112 613 V. WORK OF GENERAL PRACTITIONERS OF MEDICINE. (Number of Physicians In State, 3,400) Number of physicians personally visited Number of lectures to physicians Number of circulars or bulletins to physicians.- Number of letters or post cards to physicians Number physicians reporting treating Uncinariasis Number of persons reported treated by physicians VI. EDUCATING THE PEOPLE IN SANITATION (By Field Directors). 975 12 1,073 1,408 145 262 1. By Public Lectures: ^ 100 Estimated number attending 10,709 2. Through the Schools: Number teachers visited 483 Number letters to teachers 157 1,068 3. By Bulletins, Leaflets and Other Literature: 44,742 Number other literature distributed 4. Through the Press: ISTilTYihi^r pnppT-ff ppT!:|nnnny vinifprl 79 Number letters to editors 61 78 VII. NOTES ON WORK OF THE YEAR. 1. The growth of interest among the people in sanitation has been re- markable during 1913. Counties, in many instances, have been slow to appropriate $150.00 to $200.00 for county campaigns." On the last meeting day four counties appropriated $250.00 each. 2. Dr. Lee examined the prisoners working in the State mines at Petros, with the following results: Number Examined White 100 Negro 191 The negroes aU came from the country districts where infection might be expected. All new prisoners are now examined, and treated if infection is found. 3. As the outcome of three years' agitation a model Vital Statistics law has been enacted and put into operation. Number Per Cent. Infected Infected. 22 22 TEXAS TEXAS. 75 I. INFECTION SURVEY. Infection survey, based on an examination of at least 200 children between the ages of 6 and 18 years, taken at random from the country. County Surveyed by Number Examined Number Infected Per cent, of Infection Harris Jefferson Liberty Polk... San Jacinto. . . . Walker Houston San Augustine. . Grimes Panola WaUer Orange ,. Smith. Brazoria Robertson Shelby Brazos Austin Henderson Navarro Dr. Hoch Dr. Ferrell Dr. Judkins Dr. Ferrell Dr. Brownlee . . . Dr. Judkins Dr. Ferrell Dr. Judkins. . . . Dr. Brownlee . . . Dr. Judkins Dr. Brownlee . . . Dr. Ferrell Dr. Judkins Dr. FerreU Dr. Brownlee . . . Dr. Judkins Dr. Brownlee . . . Dr. Ferrell Dr. Judkins Dr. Brownlee . . . Total 1,665 526 600 861 626 839 706 534 804 517 467 407 525 305 275 1,151 677 372 950 1,169 926 64 361 487 546 480 388 447 388 195 225 192 60 31 59 430 33 22 253 169 55.6 12.1 60.1 56.5 87.2 57.2 54.9 83.7 48.2 37.7 48.1 47.1 11.4 10.1 21.4 37.3 4.8 5.9 26.6 14.4 13,976 5,756 41.2 II. SANITARY SURVEY. Sanitary survey, based on an inspection of privy conditions at at least. 100 country homes. Type op Pbivy A B 1 58 C "26" D" 2 "87 ' E F 241 40 100 221 282 43 188 255 420 42!^ 144j "112' 323 i 40 345. 18 40 270^ Total 246 313 192 298 320 323 286 494 657 398 466 215 286 224 805 313 657 252 428 858 Index Dr. Hoch— Harris . 2 195 5 71 32 100 98 237 141 61 42 45 "112' 474 150 178 160 270 368 5e 23 3 Dr. Judkins — Liberty 11 5 Dr. FerreU— Polk... 2 38 Dr. Brownlee — San Jacinto Dr. Judkins— Walker Dr. Ferrell — Houston 'ii 4 42 2 '94" 2.25 33.7 3 42 Dr. Judkins — San Augustine 2 92 109 "26" 135 4 8 2 2 224 1 6 02 36 5 Dr. Brownlee— Waller Dr. Ferrell — Orange 5 1 Dr. Judkins — Smith Dr. FerreU — Brazoria. _ _ 92 — - 59 54.2 5 8 107 20 74 118 60 934 6 13 Dr. Judkins— Shelby 16 14 5 9 170 291 324 136 Total 2,731 3,509 7,925 76 TEXAS lis U3 »-< t~ O !-< OO CO Oa t~ »r3 e*3 CO #H .-HOI t 03 til CO z a. 03 <^«co^~ooo«t^oOT- -I (N ^y-tr-i 03 0oaDOsm-Hoo»-ioooeooir-OTO>T- z ;= o u o o SH OoOcO'^T-i^HONsocoeor^oaio-^cooO'— lO JOOt^QOCOOJirteD i--oo^HOO-^Tt«ooasTi<«>ft'-O»Oe0i-i00(OT-iQ0<0WM0Si-HC0 O) »n T-c OJ O ■■J' (O urs 00 <0 IM CO Oi b- -* -^ QO ^ ■^*< OS eo «0 oo O OS »n 1-1 00 .-H 00 O eo OS r- CO o= o r~ m t— CD CO CO iM co com *# 6 3; CKMOeOTHOOTfO COOSOCDOSOIOO-^ WC-lCOlMtMCaWff -iMIMMMWi-tN OOOOOOOOOOOOOOOOOOOC3 oooooooooooooooooooo eocoeccococoeoeceocoweocoeococccocQcoeo 3 !;1 fl ^ d d S w ' 03 3 <1> fc. ia.Sa a.S'3=.S n : £.3 s i^ £ £^ ^ 3 ^f^>: TEXAS IV. WORK OF LABORATORY. 77 Number specimens examined- Number specimens showing hookworm infection. Number specimens showing Ascaris Number specimens showing Hymenolepis Number specimens showing Trichosephalus Number specimens showing Oxyuris. Number specimens showing Tenia Saginata Number specimens showing infection ._ Number specimens negative— Total During 1913 70 1 83 1,001 V. WOR«: OF GENERAL PRACTITIONERS OF MEDICINE. (Number of Physicians in State, 5,126) Number of physicians personally visited Number of lectures to physicians _ Number of circulars or bulletins to physicians Number of letters or post cards to physicians -Number physicians reporting treating Uncinariasis Numbsr of parsons repo rted treated by physicians VI. EDUCATING THE PEOPLE IN SANITATION ^ (By Field Directors). 1,108 11,661 1. By Pubhc Lectures: Number pubhc lectures delivered.. Estimated number attending 2. Through the Schools: Number teachers visited Number letters to teachers Number pamphlets and bulletins to teachers. 3. By Bulletins, Leaflets and Other Literature: Number bulletins and leaflets distributed Number sanitary-privy leaflets distributed Number other literature distributed.— 4. Through the Press: Number papers personally visited Number letters to editors Number articles furnished'for publication.. 5. Miscellaneous: Number county officials visited Number letters to county of ficials Number pamphlets and bulletins sent to county officials. 566 46,596 300 1,491 1,491 55,512 24,567 48,608 97 69 191 578 2,280 6,840 VII. NOTES ON WORK OF THE YEAR. 1. The campaign in Texas covers an eighteen-months' period. The people are recognizing that sanitation is necessary for good health. 2. $10,500 has been appropriated for campaigns in thirty-five counties. 3. Infection has been demonstrated in seventy-five counties; the eastern one-third of the State. The physicians in the remaining two-thirds of Texas have not had the opportunity to treat hookworm disease. Of the 2,200 physicians in the infection area, 1,002 have reported treating 4,915 cases of hookworm disaae. 4. The rural school teachers and trustees have been our greatest help in reaching the rural homes. 78 VIRGINIA VIRGINIA. I. INFECTION SURVEY. Infection survey, based on an examination of at least 200 children between the ages of 6 and 18 years, taken at random from the country. County Surveyed by Number Examined Number Infected Per cent, of Infection Albemarle Amelia Appomattox . . . Augusta Buckingham . . . Charlotte Dickenson Fluvanna Hanover Lee Nelson Orange Prince Edward. Rockingham. . . Rockbridge. . . . Spottsylvania . . Surrey Sussex Tazewell Washington. . . . Wise Dr. Brumfield. . . Dr. Miller Dr. Miller Dr. MiUer Dr. Kolmer Dr. Brumfield. . . Dr. Brumfield. . . Dr. Miller Dr. Lickle Dr. Brumfield. . . Dr. Brumfield. . . Dr. Brumfield.. . Dr. MiUer Dr. Miller Dr. Miller Dr. Lickle Dr. Kolmer Dr. Kolmer Dr. Brumfield. . . Dr. Brumfield. . . Dr. Brumfield. . . Total 330 373 1,303 451 918 404 840 485 201 1,969 218 1,029 1,250 951 989 589 490 863 1 340 1 220 815 83 52 393 82 264 95 391 16 87 759 45 210 316 97 188 59 89 245 5 21 396 25.1 13.9 30.1 18.2 28.7 23.5 46.5 3.3 43.2 38.5 20.6 20.4 25.2 10.2 19.0 10.0 18.1 28.4 1.4 9.5 48.6 15,028 3,893 25.9 II. SANITARY SURVEY. Sanitary survey, based on an inspection of privy conditions at at least 100 country homes. Type op Privy Sanitary Doctor and County A B C D 4 4 3 E F Total Index 76 122 86 53 167 123 80 122 152 20 203 207 211 205 203 4.2 1 .... 6.7 Dr. Fisher — Henry 4.4 Dr. Fisher— Patrick. 2.6 Dr. Fisher — Roanoke 2 2 1 ._.. 14 25 10.9 Total 604 497 1,029 VIRGINIA OS < Z b H Z O o b O O III 2,739 906 2,151 1,914 57 6,996 1,491 438 36 1,095 237 465 1,116 3 K H Q I? < 1 « 1 s 1 0) 0,-teOT-,ec03-*»-Htot^iot.- CJCOt^O CO-*^ CO ^co (D 1 ^HOT-Heo,-ieooa^-H-eot^ioi^ Oicot^eo co.*,-t P3 H-fCO to s o MMC-00cncqr^cD(NiOO5>OM 0 ooooooooooooo 0C300000000000 o o M c a Wise — Brumfield Dickenson— Brumfield. — Hanover— Miller _ _ Appomattox — Miller Roanoke — Lickle Lee — Brumfield : Pr. Edward- Miller. Surry — Kolmer. Tazewell— Brumf ield Sussex — Kolmer Amelia — Miller Charlotte— Brumf ield Buckingham — Kolmer 'c3 IV. WORK OF LABORATORY. Number specimens examined Number specimens showing hookworm infection- Number specimens showing ABcaris . Number specimens showing Hj^menolepis Number specimens showing Trichocephalus Number specimens showing Oxyuris Number specimens showing Tenia Saginata Number specimens showing infection Number specimens negative Total During 1913 8,021 1,338 1,587 26 229 15 3,127 4,894 V. WORK OF GENERAL PRACTITIONERS OF MEDICINE. (Number of Physicians in State, 2,357) Number of physicians personally visited., _ Number of lectures to physicians. Number of circulars or bulletins to physicians __ Number of letters or post cards to physicians Number physicians reporting treating Uncinariasis Number of persons reported treated by physicians VI. EDUCATING THE PEOPLE IN SANITATION (By Field Directors). 4,600 6,900 363 1,264 1. By PubUc Lectures: Number public lectures delivered— .. . . _...-.._ 620 52,015 2. Through the Schools: Number teachers visited 405 450 3. By Bulletins, Leaflets and Other Literature: 37,000 Number sanitary-privy leaflets distributed „ 30,000 Niimhftr nthpr lit.Rrn.t.nrft Hintrihiit.ftd 4. Through the Press: Nninhfir papprs pfirRrtna.lly vi.tiitpirl 38 110 VII. NOTES ON WORK OF YEAR. 1. During the year 102 privies were buUt at rural colored schools in the twenty-five counties which now have a colored rural school supervisor. 2. The State Board of Education has served notice on all local boards of school trustees that sanitary privies must be erected during the coming year under penalty of withdrawal of State aid. 3. On Liacoln's birthday 35,000 colored children received instruction in the sanitary catechism prepared by the Department, and including matter on hookworm disease. 4. A personal visit by the State Director to Richmond county, where work was first begun in May, 1910, showed marked improvement in the economic conditions of the inhabitants of the heavily infected Haynesville district. (See map, fig. 19.) 5. During the year, through co-operation with the University of Virginia and the State Health Department, complete medical inspection was made of the school children of Orange county, including examination for animal parasites. 6. During the year 903 treatments were sent to physicians upon request for their patients. CHAPTER III. HALF-TONE ILLUSTRATIONS -5 t. QJ P bD S s ,& ■» = 1 >*<-7 vy?. *? p '" ^a-''^* *v »A^ _ o ^ ^>' P SI . c is OS r bo '^-^■^■-K --A Fig. 41-42 — Map shows States where county dispensaries have operated. Number of counties in the eleven States, 1,142; work completed in 411. > "f^. 2£ . ,r I'- y , i% { i CHAPTER IV. A FEW TYPICAL LETTERS AND EXTRACTS FROM LETTERS SHOWING THE CO-OPERATION OF VARIOUS AGENCIES, AND THE ATTITUDE OF THE PEOPLE TOWARD THE WORK. I. Letters and extracts from letters by physicians. (1) Dr. Grote, Field Director, to Dr. Dinsmore, State Director, Ala. — "Dr. Miller of Myrtlewood came all the way from his home place, a distance of eighteen miles over muddy roads, through the rain, and brought thirteen specimens from his patients, all of whom were infected. Drs. Stone and Brasfield have both attended the clinics to-day." (2) J. P. Masterson, M. D., Bessmay, Tex. — "My dear Doctor: Your commission has just closed operations in Jasper County, and to say that it has done great good, and has been a grand success, would express it only mildly. The money appropriated by our county does not in any way compare with the great good that has been done for the county at large, and even the worth it has been to just one individual infected with hookworm disease. It has enabled and en- couraged numbers to be examined and treated, that otherwise would not or could not have been." II. Letters and extracts from letters by county health officers. (1) Karl Chambers, M. D., County Health Officer, Jasper, Jasper County, Texas. — "Dear Doctor: Over and above the 1,133 treatments dispensed here, the campaign was worth thousands of dollars to the county in an educational way, for the people now realize that improving insanitary environment is imperative. The campaign in this county has received 82 ILLUSTRATIVE LETTERS hearty commendation from every man, woman and child so far as I personally know, and I feel sure that the results ob- tained warrant all the praise given." (2) Dr. W. S. Leathers, Jackson, Miss. — "Dr. Whitfield on entering Smith County obtained the aid of Dr. Carr, the County Health Officer, on a three weeks trip through the county. This was done at the suggestion of Dr. Carr and at his expense. The County Superintendent of Education used every possible means to enlist the interest of the teachers and children of the schools. This is one of the interior counties and a feature of the work was the unanimous support of the Board of Supervisors. This was clearly shown by obtaining a second appropriation for the campaign without any diffi- culty." (3) V. J. Cragg, County Health Officer, Clanton, Ala. — "Dear Doctor: The work here has been a great success from every point of view, and I am quite sure that there was a much higher per cent, of infection in this county than was even dreamed of by the majority of the profession, not to speak of the matter from the standpoint of the laity. I feel that much good has been done by teaching the laity the very important matter of prevention as well as the work of treating the patients, who are at present infected." (4) Dr. M. H. Boerner, State Director, Texas, to Wickliffe Rose, Washington, D. C. — "Dear Mr. Rose: I am en- closing you herewith a plan for grading thirty-five schools in Brown County. They are contesting for the One Hundred Dollar Sanitary Prize, offered by Dr. J. W. McCarver for the school that attains the highest grading." ILLUSTRATIVE LETTERS 83 (.Type of Plan Followed to Improve School Sanitation.) To THE Public To become an effective instrument for the protection of child-health, it is essential that the school should be a sanitary and healthful place for children. Recognizing the importance of this broader humanistic re- sponsibihty of education, it has been thought wise to inaugurate a clean- up campaign among the schools of Brown County, and through the gen- erosity of Dr. J. W. McCarver, our county health officer, and Mrs. S. R. Coggin, former president of Coggin National Bank, a prize of one hundred dollars is to be awarded the most sanitary school. Dr. McCarver offers $50.00 in cash to be expended in any way it suits the winners, and Mrs. Coggin donates 150.00 for books for school library and periodicals. " Every school in Brown County (outside of Brownwood) is eligible for entry; those interested will please mail a card to the county superintendent by March 1st. The humblest, most unattractive school house will stand an equal chance with the newest and prettiest, as the matter of beauty will not be considered and the judges will grade all schools on a sanitary basis alone. The following points will be considered, each of the four headings being worth 25 per cent. 1. House — Ventilation, cleanliness, state of repair. 2. Grounds — Drainage, trees, provision for healthful sports, rubbish, etc. 3. Water — Source, container and cups, freeness from pollution. 4. Toilets — See or write to Dr. J. W. McCarver for particulars. This contest wiU close the last day of March, 1913, and judges will begin inspection on March 15th. The time is short, so let teachers, trus- tees, mother's clubs, fathers, sisters, brothers, uncles, aunts, and cousins lend the children a helping hand in this great work. Let this clean-up movement be the greatest trust ever organized in Brown County; its dividends may not be counted in dollars and cents alone, but in brighter faces, rosier cheesk, keener intellects and happier co-workers with our Maker in the progress of civilization. (Signed) Mks. E. L. Walker. 84 ILLUSTRATIVE LETTERS III. Letters from High Officials. Hon. Earl Brewer, Governor — To the People of Mississippi: The importance of the laws of Sanitation and Hygiene is now being brought to the attention of our people as never before. The School Improvement Association, under our State Department of Education, and State Board of Health, are doing their utmost to educate our people on this subject. Particularly are our children being taught the necessity of clean living, and those rules which if followed, will give them immunity from so many of those diseases which interfere with their work at school, and cause ill health in maturer years. The School Improvement Association has issued a program to be observed in all our public schools, and I most heartily commend it. To emphasize the importance of this question and show my interest in it, and in order that it may be brought to the at- tention of our people, I do issue this PROCLAMATION calling on them to observe Friday, October the Thirty-first, 1913, as HEALTH DAY, and on this day that their energies be redoubled, and their faculties brightened so as to acquire that definite knowledge which IS necessary for better health and better living. The Great Seal OF THE State of Mississippi In Testimony Whereof I Have Hereunto Set mt Hand and Caused the Great Seal of the State of Mississippi to be Affixed, this, the Thir- teenth Day op September, A. D. 1913. (Signed) Earl Brewer. By the Governor Joseph W. Power, Secretary of Stale. ILLUSTRATIVE LETTERS 85 (2) Jas. K. Vardaman, U. S. Senator from Mississippi. — "Dear Doctor: I think the State of Mississippi is to be con- gratulated upon the great work that you and your co-laborers are doing in the interest of health and sanitation. If I had been told some years ago that hookworm was so prevalent in Mississippi, I could not have believed it. The disease has done a great deal of damage, and those engaged in exter- minating it deserve the gratitude of all men. The same thing is true with reference to pellagra, tuberculosis, typhoid fever, and in matters of general sanitation. If I can be of any assistance to you in this great undertaking please command me." ' ' To Dr. W. S. Leathers. IV. Letters and extracts from letters by teachers. (1) Edward F. Green, President Carolina Collegiate and Agricultural Institute, Star, N. C. — "Dear Doctor Pridgen: Permit me to say that the examination showed 47% of our students were troubled by the Hookworm pest. There had been a noticeable lack of interest both in play and in the studies on the part of a goodly number of the students. The treatment given by Dr. Covington was marked, and to a no- ticeable degree even on the part of people not watching the effect of the treatment closely. In the classroom the im- provement was very perceptible in the growing interest in the work, and the grip the students got on their studies. The pallor went from the faces, and there was a manifest desire to take part in the games on the playground after the treatment. It was a rejuvenation in a very real sense." (2) Exhibits from two institutions showing difference in efficiency which seems to have been caused by a light infection: 86 ILLUSTRATIVE LETTERS (a) Blue Mountain Female College: Average grade of 56 girls who were found infected . 77 . 75% Average grade of 56 girls taken at random not in- fected 89.28% Of two sisters in this college, grade of one infected .78 % Grade of other not infected 87 % (6) Mississippi Heights Academy: 5 young men not infected (ages 20 to 28), average grade 92 . 2 % 5 young men infected, average grade 89. 8 % 5 boys not infected (ages 12 to 17), average grade. 84. 2 % 5 boys infected, average grade 81.0% 25 men and boys not infected, average grade. . . .86.0 % 25 men and boys infected, average grade 64.0 % 3. Examina'ion of Students at the A . &f M . College, Missis- sippi. — At A. & M. College, Mississippi, 819 students were examined for hookworm infection, of whom 323, or 39% were found infected. An examination of those students coming from sandy counties showed 69% infection. A series of 625 of these students showed only-one athlete infected; an' ex- amination of the 144 officers showed only five infected. Twenty-five men, five feet ten inches tall, not infected, averaged in weight 156 pounds; twenty-five men, five feet ten inches tall, infected, averaged in weight 147 pounds. ILLUSTRATIVE LETTERS 87 Of the twenty-five not infected: 5 made an average of 90 and above 1 1 made an average of 85 5 made an average of 80 3 made an average of 75 1 made an average of 65 Of the twenty-five infected: made an average of 90 1 1 made an average of 75 2 made an average of 85 3 made an average of 80 9 made below 75 V. Description of Work by Field Directors. (1) Dr. J. S. Lock, Field Director, Williamsburg, Ky., to Dr. McCormack, May 13, 191J. — "Dear Doctor: This has been the banner day in my dispensary work. We have had a total of 881 specimens brought in. The entire county is greatly aroused. Every county official, including the magis- trates from the different sections, have been present all day aiding in the work. Every doctor in town was out, and gave the entire day to the work." We worked on the court house lawn, and fully 25,000 people were present during the day. The people said we had as large a crowd as they had ever seen in the town on any occasion." (2) Dr. Lock, Field Director, From Bush, Laurel County, Ky., July II, 1913. — "After all the specimens were in to-day, we made our count, and found that we had examined 328 specimens, and that we had 1,359 specimens (a total of 1,687) to send to the laboratory." Note — This is the record for the largest number of speci- mens brought into a dispensary for any one day. 6,381 per- 88 ILLUSTRATIVE LETTERS sons were examined in Laurel County, Ky., in twenty-one days. (3) Dr. Henry Boswell, Field Director to Dr. W. S. Leath- ers, State Director, Miss. — "Dear Doctor: I have just finished the work in Prentiss County. We examined about one-third the total population. I have not before seen such interest manifested, nor more permanent results obtained. "The co-operation was excellent. The county of ficials gave their influence and time to promote the work. The Chancery Clerk attended to the central office work throughout the pre- liminary campaign. "At one dispensary three small boys came each week two or three miles. They always rode three little bulls, which seemed to saddle very well and to attract much attention. "At Thrasher, the co-operation of one woman was note- worthy. She combatted disbelief and prejudice in her com- munity. In phoning one morning for 25 specimen containers to distribute, she said: 'I succeeded in getting one of these fellows to have examination made and to take treatment. He is feeling better and has gained in weight. Now that the peo- ple have seen that the medicine did. not leave him blind or crippled, but is actually helping him, they are wanting to be examined.' The woman was instrumental in having about one hundred persons examined. "A young man that we treated furnished us the best recom- mendation that we could have had. He came to the office about the third week looking as if he had the worst case of tuberculosis, and with a cough that appeared serious. He was such a picture of dejection, misery, and lost hope, chat he attracted the attention of the whole court house crowd and many of them watched eagerly to see the results of the ex- amination. One man asked me, after he left, if I could cure ILLUSTRATIVE LETTERS 89 him, and I replied that we would do oui best. This man then kindly stated that he thought that I was doing the boy an actual wrong by holding out a hope, as it was his belief that the boy would die in a very short time. This boy was in- structed to return every week for his treatment until informed that he was cured. He did; and it was a standing request by the court-house officials that they be called each week as Willie Livingston came in, so that they could see for them- selves whether he was improving or not. On his first trip, one week later, he came in, and there was evidence of much improvement. He came in with a smile, showing more in- terest in things around, telling jokes to fellows in the office, when just one week before he had stood listless without a word to anyone except to answer yes or no when a question was put to him. He informed us that on this trip, although he had taken his medicine only a week ago, he was feeling a great deal better, and when placed on the scales, I found that he had gained a number of pounds in weight. He was given three treatments, one week apart, and after waiting two weeks following the third treatment, he was found free from infec- tion, and weighed eighteen pounds more than he did previous to the first treatment. On the day that he first appeared at the dispensary he could hardly walk, and the last time that I saw him he started with another boy to walk seven miles to his home. As he left the Chancery Clerk said, 'Well, if you had done nothing but treat this one boy of this county, the money would have been well spent.' "Another man, a Mr. Chase, came up and thanked me say- ing: 'I have lost two boys, and the others had begun going down in health, just as they did, but thank God, they will be saved, because you have told me what the trouble is, and have cured them.' "As I closed the office on leaving for the next county, a mem- . 90 ILLUSTRATIVE LETTERS ber of the Board of Supervisors came by and said that if I would stay in that county they would double the ap- propriation, that nothing they had ever done had accom- plished the good of this work, and that it was a work that was appreciated by every citizen of the county. "It might be mentioned that some school buildings were repaired, sanitary con\'eniences provided, and likewise the sanitation of the entire county improved. "Trusting that I may be able to do as good work in the next county, I am." (4) Dr. M. W. Steele, Field Director, Kentucky, to Dr. A. T. McCormack, State Director. — "Dear Doctor : I have just closed the campaign in McCreary County with 5,252 examinations. This campaign has been one of unusual interest and has been very successful in every particular. We have found the hook- worm infection about 57%. One locality about Buzzard Post Office showed 91% infection. The roundworm infection has been very high ; found the usual number of cases of whip- worm and dwarf tape worm. Practically all cases of infec- tion have been treated with splendid results. The results in some cases have been almost miraculous. "One good old lady was interested.to take containers and go among the shy girls, and secure specimens and bring them in, and she would in turn deliver the treatments and give in- structions. The results have been so splendid that I cannot picture to you how grateful the people are. People through- out the country hearing of our work came from all sections to know about the good work, and to be examined. The demand became so great for a county wide campaign that it became almost compulsory upon me. "Mr. W. B. Creekmore came from Pine Knot and proposed to do anything in his power to help us, insisting that his people ILLUSTRATIVE LETTERS 91 must have the benefit of the work. Then came Mr. Walker and E)r. Cain from Cumberland Fails, and others proposing to bear any part of the expense necessary. "Messages were sent to the State Board pleading for a con- tinuation of the work. I proposed if the Fiscal Court would bear the expenses of my assistants while in the county, that I would comply with the requests ; but what about this matter. At that time there was a contest on for the judgeship and a bitter feeling existed in some sections. The county seat question was being hotly contested, but everybody wanted our work to go on; in fact, they would not let us leave. One claimant to the judgeship with four of the six magistrates met and allowed a fund for the expense. The other claimant to the judgeship gave me an order on the treasurer. Because of legal questions aside from this matter the treasurer was afraid to pay over the money, but joined with others in urging that our work must not stop. One Mr. Kinna, a patriot in the cause, came to the rescue of the matter and advanced the necessary funds on the order of the court. Both claimants to the judgeship served on a citizens' committee, and approved of a schedule of dates and places for our investiga- tion. We then made these places in their order, giving lectures, visiting homes, meeting people in squads on the roadside, and treating hundreds of cases. Everybody seemed to be helping, and I am told that this subject is the talk of every home there. These are a splendid people, ah appre- ciative people. A very small per cent, are educated, but they manifest the highest type of common sense. There are no foreigners and but very few negroes in the county. All are natives of good names — Stevens, Creekmore, Bell, Worley, Foster, etc. "Judge Williams, who had been declared the rightful Judge, said, keep up the work at any expense, and it will be taken 92 ILLUSTRATIVE LETTERS care of. It will interest you to know that one old lady walked ten miles to have her family examined. The following day she returned and asked for a box of containers for her neigh- bors. She went among them on foot and secured 146 speci- mens in one day. She later delivered the treatment in the same way. She could not read, but said she took along a little boy who could read to deliver the treatments. "Four men came horseback from Wayne County yesterday to learn what is to be expected of them to get the work ex- tended there. Many have come from Pulaski County and the County Judge says 'come as early as possible. I will give one hundred to start on and call the Fiscal Court together, if necessary, for the balance.' "We are coming in for a few days. Will see you." (5) Dr. 0. H. Judkins, Field Director, Texas, to Dr. Boerner, State Director. — "Dear Doctor: We are completely swamped. It is a physical impossibility for the boys to examine these specimens. There has been a constant stream of people passing through the dispensary all day, and we have had to lock the doors to keep them out. I have talked to them in squads of about 250 in the District Court Room when they would overflow the office. We are sending the specimens to you. "One box of specimens was sent in from St. Mary's Seminary, LaPorte. These are in a box by themselves, and the report can be sent to Rev. J. M. Kerwin, St. Mary's Seminary, La- Porte, Texas, and it will be necessary to fix the treatments up there and send with the report." CHAPTER V. REPORT OF THE SCIENTIFIC SECRETARY Addresses. — During the year 1913 I have given 73 addresses bearing upon the pubHc health subject of hookworm disease and soil pollution, and In addition to these, several addresses have been given by my Private Secretary. Lantern slides. — The State Boards of Health now procure their slides directly from the manufacturer, instead of through my office, but I still continue to keep on hand several sets to loan to physicians, teachers, and others who wish to give addresses on this subject. Microscopic diagnosis. — The State Boards of Health have now had so much experience in the microscopic diagnosis of intestinal worms, that it is only in exceptional cases that specimens are referred by them to me. Field work. — The greater part of my time this past year has been given up to certain field studies in County Z . . and in County X . . . The results of the work is County Z . . are now nearly ready for publication, and will soon be issued. One entire month was spent in campaigning certain counties in two states in the interest of better sanitation. Investigations. — Of the various investigations under way, or recently published, it is desired to report formally at present only the following: (a) A Test to Determine Fecal Contamination of Food. — For some time past, I have not been able to escape the con- viction that improvement in sanitation is not resulting so rapidly as is desirable. The lay mind is aroused in the face of an unusual epidemic that affects business, but seems fairly well contented to permit long-existing conditions to continue 94 REPORT OF if the annual death rate is not much higher than usual, despite the fact that this rate may be unnecessarily high. An active desire for better sanitation in this country is found chiefly among a relatively small proportion of the medical fraternity, in a relatively much greater proportion of the public school teachers, and in some members of women's clubs. The aver- age American has very little idea of sanitation and very little intei'est in it. Two important new developments are, how- ever, the increased interest among certain life insurance com- panies and certain senators and congressmen, exhibited along the line of popular education for better health protection. It has seemed to me that we have possibly lacked a method of putting the subject before the average lay mind that will be sufficiently striking to arouse popular interest, and I have been giving considerable time and thought to the possible development of some new point of attack. At present, I believe that I have a method that will appeal to the average person, at least to the extent of inducing him to think of the conditions under which he is living. We find in the intestinal tract of man three minute pro- tozoan organisms that are obligatory parasites, that i^ to say, these organisms spend their motile stage as parasites, while their non-parasitic existence is confined to spore stages that serve to transmit the infection from one person to another. These three parasites are known as Entamoeba, Laniblia, and Trichomonas. Since they are obligate parasites and since they could not arise by spontaneous generation, their presence in a person's intestine is proof that the person in question has swallowed material discharged from some other person's intestine. The spores are discharged in the feces and can be easily found in privies. There are several conceivable methods of transmitting these organisms from one person to another, but I am persuaded SCIENTIFIC SECRETARY 95 that so far as the regions are concerned in which I have been working, the ordinary method is by means of the flies that breed and feed in human excrement, and that these insects carry this material and the protozoan spores to the kitchen and dining room, and smear it on the food. In experiments that have been made at the U. S. Marine Hospital in Wil- mington, we have succeeded, in fact, in recovering the spores of Lamhlia from flies that have visited human excreta, The parasites mentioned have a very wide geographic dis- tribution. In this country, one or another of these genera is known" from New York State on the North, to Alabama on the South, and to CaHfornia on the West. Thus, a plan of campaign for better sanitation, based on the finding of these protozoa, can be carried out in practically any part of the country. The method I am trying to present is this: Specimens of fecal material are collected from a number of people, prefer- ably at first, from the children of the more educated and more refined people in a town; these specimens are examined not only for intestinal worms, but also for these protozoa. In case any of the three genera in question is found, the mother of the child is notified by mail that the microscopic examina- tion gives positive evidence that her child has eaten food con- taminated, probably by flies, with human excreta, and she is advised to request the local health officer to inspect the block in which she lives to see whether there is not some insanitary privy near-bj' that is supplying their table with infected flies. Although this line of educational work is still in its infancy, it is already safe for me to conclude that these letters are fol- lowed by a greater and more emphatic demand for the aboli- tion of the surface privy than I have thus far met with in a 13-year campaign against soil pollution. It is an interesting point of considerable practical import- 96 REPORT OF ance that seemingly only one family has thus far taken offense at the receipt of these letters. As an indication of the frequency of these parasites in stools not obtained with salts, it may be stated that recently in a. group of 187 unselected cases, the following results were obtained : People Living in Homes Result of Examination With Sewer With PriVy Number Per cent. Number Per cent. Negative . . . 88 22 80 20 54 23 70 Protozoa present 30 Total 110 100 77 100 Protozoa found: Entamoeba coli Lamblia 9 9 2 2 8 8 2 2 6 14 3 8 18 Trichomonas Undetermined genus . 4 At present I have arrangements completed to apply this test of unconscious coprophagy to all the school children, white and black, of an entire county, and if the results in education along sanitary lines are equal to the present indica- tions, I shall extend the work to other localities. Four State Health Offices have already invited me to make State-wide tests in their States. I must confess that the slowness of improvement in sanita- tion in the last 13 years, in the United States, is a very distinct SCIENTIFIC SECRETARY 97 disappointment, but I am rather persuaded that this new test by which we can state to the mothers that we have proof that their sons and daughters have actually swallowed material that has come from the bowels of some other person (though we cannot state whether that person was white or negro), places aL our disposal a method by which we may in the next 13 years create a more active and more intelligent demand for sewer connections or for the sanitary privy than has re- sulted from the past 13 years work. While the protozoa and flies in question are far removed from the subject of hookworm disease, from one point of view, it will be seen that when it comes to an improvemenc of the sanitation in order to eradicate hookworms, these protozoa and flies are able to furnish us with more appealing argu- ments than even che hookworms. {b) Effect of Light Infections. — There scill exist a number of persons who believe chat light infections with hookworms are of no clinical importance. This past year it has been possible to study certain phases of this subject and the results will soon be published. For the present all that I desire to state in this connection is that the view that infection with say less than 100 or 50 hookworms is clinically unimportant is nega- tived by the fact that treatment of such cases has resulted in showing that the children in question have made greater improvement in certain respects, in a given time, than has a control group of childien who did not show hookworm infec- tion and a contiol group of children who did have the infection but were not treated. A study of the full results of the work in this investigation will require several months longer before the manuscript will be ready for publication. (c) The U. S. Marine Hospital, Wilmington, N. C. — Prior Lo 1913, I have for several years past transferred my work 98 REPORT OF in the summer from the Hygienic Laboratory at Washington, D. C, to the Marine Hospital at Wilmington, N. C. Last spring, the Surgeon-General transferred me to Wilmington to take charge of this hospital, so as to give to me in my hookworm work the advantages that naturally resulc from being constantly in the area of infection. The policy of ultra- economy in its hospitals forced upon the U. S. Public Health Service because of the existing appropriations has not per- mitted the expansion of the work for which plans exist, but I am greatly in hopes that a change of policy will soon be possi- ble. In the meantime, the facilities of the hospital are being used for laboratory purposes and are thus presenting greacer advantages along certain lines than I could possibly have in Washington. Publications.^The following articles bearing directly or indirectly upon the hookworm campaign, have been printed: Stiles, (C. W.): 1913a. Hospital relief for the country. The possibilities offered by hospital trains in furnishing much needed medical and surgical facilities to rural districts. < Public Health Reports, Wash., V. 28 (5), Jan. 31, pp. 208-212. 1913fc. Idem. Reprint No. 115, U. S. Public Health Service. 8° Washington, pp. 1-7. 1913c. Country schools and rural sanitation. Six samples public schools in one county. Does this county need medical in- spection in its public schools? The country school teacher. < Public Health Reports, v. 28 (6), Feb. 7, pp. 247-249. 1913(Z. Contamination of food supplies. The value of protozoa as an aid in determining fecal contamination of the food supply.