Popular Science Monthly/Volume 82/April 1913/United States Public Health Service

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UNITED STATES PUBLIC HEALTH SERVICE[1]
By ALFRED C. REED, M.D.

ASSISTANT SURGEON, UNITED STATES PUBLIC HEALTH SERVICE

THE wide-spread ignorance of the various means employed by the federal government to promote the well-being of its citizens is nowhere better exemplified than in the common ignorance of the functions and important work of the Public Health Service. This ignorance is the more lamentable inasmuch as the Public Health Service is the sole national agency operating to combat and prevent epidemic diseases among human beings, and to improve public sanitation and hygiene, in the United States. The awakening national conscience in public health affairs lends peculiar interest at this time to a consideration of the varied and important functions exercised by this service, and the fascinating history of its achievements.

The Marine Hospital Service is one of the oldest and most peculiarly American of all our institutions. Its beginning was in an act of congress of July 16, 1798, which put a tax of twenty cents a month on every seaman of the United States, to be taken from his wages. The occasion for this procedure had been well explained by Hon. William Williamson in the House of Representatives away back in 1792.

Wherever it is probable that sailors may be sick, there I would make provision for their support and comfort. Hospitals should be erected or lodgings hired at every port of entry in the United States, for sick and infirm seamen, where they may be properly attended during their indispositions. The money to be collected at the several ports as hospital money should be expended in those same ports alone, under care of such a person as may be designated for that purpose.

The first hospital owned by the government was at Washington's Point, Norfolk County, Virginia. This was purchased in 1800. Three years later a Marine Hospital was completed at Boston. At about the same time, the money collected by taxation of seamen was transformed into a general fund for medical relief work among sailors. The same legislation made provision for the establishment of the service in New Orleans, which was not then a part of the United States.

After a time the seamen's tax was not sufficient to maintain the constantly broadening work, which had to be correspondingly restricted in its usefulness. No chronic or incurable diseases were treated, nor was any patient kept longer than four months. Sailors in those days fared poorly, and their life was a hard one indeed. Especially was this true on the Mississippi River system, which was a great water-highway

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Hygienic Laboratory, U. S. Public Health Service, Washington, D. C.

 

and the principal means of commerce and communication over a vast territory. Often a flatboat starting from the upper river would lose its entire crew of five or six men by disease before reaching New Orleans. During the severe cholera epidemic of 1832 and 1834 the lot of the rivermen was especially severe.

It became necessary for congress to assist the service work by annual appropriations. In 1837 the original Marine Hospital was built in New Orleans and provision was made for purchasing sites for hospitals in three inland zones. Along the Mississippi River stations were located at Natchez, Miss.; Napoleon, Ark., and St. Louis, Mo. On the Ohio, the chosen points were Paducah, Louisville and Pittsburgh. The center for the Lake Erie sailors, was at Cleveland. The first Marine Hospital at Chicago dates from 1848 and was built on land adjacent to old Fort Dearborn. The second hospital, the present one, was authorized in 1864 and opened for patients in 1873. It occupies a beautiful location on the lake shore five miles north of the harbor.

The first service establishment on the Pacific Coast, at San Francisco in 1851, was on the contract basis. A hospital was erected three years later, a commodious and well-built structure, doomed to serious injury in the severe earthquake of 1868. The contract system with other hospitals was then resumed and continued until the completion of the present building in 1875. During the Civil.War many marine hospitals in both the north and the south were converted into military hospitals. Those at Boston and Norfolk were used in this capacity in the war of 1812.

In 1870 congress reorganized the service and Dr. John M. Woodworth, of Illinois, was appointed supervising surgeon. Within the next three years, the service began to attract considerable attention in foreign countries. London medical journals bestowed lavish praise on this uniquely American institution. At this time service officers were requested by the supervising surgeon to inform themselves fully as to local health regulations and to assist, when requested, in their enforcement.

Upon Dr. Woodworth's death in 1879 President Hayes appointed Dr. John B. Hamilton to succeed him. The year before Dr. Woodworth's death marked the occurrence of a terrible epidemic of yellow fever in the Mississippi Valley. With this freshly in mind, congress added quarantine control to the growing functions of the Marine Hospital Service, but failed to make any appropriation for its operation. Then a year later, in 1879, a law was passed creating a National Board of Health to exercise quarantine functions for four years. At the end of that period, the law of 1878 was revived, and national quarantine passed permanently into the hands of the Marine Hospital Service. The entire development of the quarantine service took place under the wise guidance of Dr. Hamilton.

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Marine Hospital, Staten Island, N. Y.

In June, 1891, Dr. Hamilton resigned to be succeeded, by the appointment by President Harrison, of Dr. Walter Wyman, who had been chief of the quarantine division in the administrative bureau. In 190? the enlarging and changing functions exercised, necessitated a change in name from the old Marine Hospital Service to the cumbersome but expressive Public Health and Marine Hospital Service. In 1893 additional quarantine powers were added and additional responsibilities imposed, such as the medical inspection of immigrants. In 1875 the supervising surgeon became the supervising surgeon general, and was commissioned. By the legislation of 1889 commissions were conferred on all the regular officers of the corps. The old seamen's tax was finally abolished in 1884 and since then the service has been supported entirely by Congressional appropriation.

Examinations are held annually at Washington for candidates for admission to the corps. No more rigorous test is to be found for any medical appointment than this, lasting from a week to ten days or more. The examination covers the physical condition, literary and academic preparation, and practical and theoretical training. It includes a practical laboratory and hospital bedside examination. After four years assistant surgeons are eligible to be examined for promotion to the next grade of passed assistant surgeon. After from fifteen to twenty years' service, further examinations are held for promotion to the grade of surgeon. There are now 135 commissioned officers. This service offers one of the most attractive openings in the country for young physicians.

The splendid institution known as the Hygienic Laboratory, now recognized the world around for its excellent contributions to the knowledge of scientific medicine and of public health and sanitation, was founded just twenty-five years ago as a laboratory of pathology and bacteriology in the old marine hospital at Stapleton, Staten Island. At first all of the work was done by one officer in the intervals of his attendance in the hospital wards. After four years the work was transferred to Washington, where it has been ever since, and until 1894 was housed on one floor of the service office building. About this time the advantages began to be realized of using this laboratory as a training school for officers, supplemented with details abroad affording opportunity for visiting the great centers of London, Paris, Berlin, Vienna and other cities.

Among the earlier subjects taken under consideration were disinfecting methods as applied to quarantine and epidemic practise. These investigations resulted in the elaboration of a system of disinfecting apparatus, together with disinfecting agents and a method for their application, which now stands unrivaled. This laboratory was probably the first to recommend formaldehyde in place of the older disinfectants, steam, carbolic acid and sulphur dioxide. The first authoritative publication on the use of diphtheria antitoxin was issued by the Marine Hospital Service, and the first diphtheria antitoxin made in the United States was produced in the Hygienic Laboratory. Both resulted from personal instruction received by an officer from Behring and Roux, who had separately announced their discovery at a meeting of the International Congress of Medicine at Budapesth.

In March, 1901, congress appropriated $35,000 for the necessary buildings, and directed the cession of five acres of land from the old naval observatory site by the secretary of the navy for the use of the Hygienic Laboratory. After the legislation of July, 1902, which increased the functions of the Marine Hospital Service and changed its name to the Public Health and Marine Hospital Service, the scope, organization

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Chicago Marine Hospital.

and personnel of the laboratory were greatly extended. An advisory board was created, consisting of officers from the Army and Navy Medical Corps, a scientist from the Bureau of Animal Industry of the Department of Agriculture, and five men from civil life, who were to be skilled in laboratory work bearing on public health problems. These five at present are Victor C. Vaughan, dean of the School of Medicine of the University of Michigan; William Welch, professor of pathology at Johns Hopkins University; Frank Wesbrook, professor of pathology at the University of Minnesota; Simon Flexner, of the Rockefeller Institute; and William T. Sedgwick, professor of biology at the Massachusetts Institute of Technology.

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Rear of Stapleton Marine Hospital, showing Tents for Tuberculosis Patients.

Three additions were made to the original divisions of pathology and bacteriology. These were medical zoology, chemistry and pharmacology. Medical zoology embraces the study of parasitic diseases of man. Under pharmacology, drugs are examined as to purity, potency and action, and important work is done on the standardization of drugs. By another act of July, 1902, provision was made for the licensing of all establishments engaged in interstate traffic in viruses, serums, toxins, antitoxins and analogous products. Samples of such products are bought in the open market and tested for purity and strength. The manufacturing establishments are inspected by medical officers, both before and after the license is granted. Fines and suspensions or withdrawal of license are the penalties for false labeling or faulty methods of production.

The laboratory makes a practise of assisting health officers of states and communities which have no reliable laboratory facilities, by analyzing samples of water, as to impurities, infection and potability. investigation has likewise been made of the hygiene and sanitary arrangements of railroad coaches and sleeping cars. The question of the dissemination of malaria by mosquitoes has been another productive field of research.

Closely connected with lines of work already outlined, is that of the leprosy investigation station on Molokai, Hawaii. Here, with unlimited material at their disposal, the director and his able assistants are making careful studies of the lepra bacillns, with the ultimate ambition of producing some means for the prevention and cure of the disease. A good example of the thorough and painstaking study of epidemic disease which characterizes the service work, is the exhaustive research made by Stiles of the distribution and results of hookworm infection in the south and especially in the rural sandy districts of Georgia and Florida. What Stiles did for the south, Ashford and King did for Porto Rico, and the result has a large economic, social and sanitary value in both places.

Relief stations of the service are divided into four classes. The first-class stations, numbering 23, consist of a marine hospital under the command of a commissioned officer. Among these is included the tuberculosis sanatorium at Fort Stanton, N. M. After the subjugation of the Apache Indians, the old army post at Fort Stanton, which for forty years had been a frontier protection for ranchmen, was no longer necessary, and in 1896 it was abandoned. For three years the post was deserted, except for the wild desert prowlers, and sagebrush and decay replaced the busy military life which had known it so long. In 1899 the property was acquired by the Public Health and Marine Hospital Service, and again the martial spirit took possession, and once more the stars and stripes floated over the parade ground, fanned by the health-bearing breeze of the New Mexican plateau. But the foe to be conquered under the new regime was not the fierce red warrior whose 'merciless and invincible spirit had been supreme against the Spaniard and the American for three hundred years. The new foe, more deadly and terrible by far than the old, was the silent and merciless white death, the relentless destroyer of thousands, the plague of tuberculosis.

In situation Fort Stanton is admirably adapted to its present purpose. At an altitude of 6,200 feet, it has winter snows, and moderate heat in the summer. The reservation includes about forty-five square miles, and has resources which, when fully developed, will go far toward making the institution self-supporting. Natural water power is available. Two thousand cattle can be pastured on the range, which now supports almost that number of beef cattle, besides a large dairy herd. Poultry raising will soon supply an abundance of turkeys, chickens and eggs, and hog raising is another industry which promises much.

The daily number of patients averages about two hundred, under the care of seven medical officers. Sixty attendants find employment

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Tuberculosis Camp

on the reservation. No unimportant function of the sanatorium is that which finds its result in the influence of the education in hygiene and tuberculosis prevention, upon those who leave after having been cured or benefited by the treatment. These men spread their new-found knowledge among their associates and so extend the actual good accomplished.

Patients come to Fort Stanton largely from sailor boarding houses and other crowded districts of the large sea ports. Some are old incurable cases, but their lives are prolonged and made more comfortable, and incidentally the Sanatorium is in effect a quarantine station, not in restraining men from liberty, but in that it keeps from the large centers of population a daily average of over two hundred consumptives who in all probability would have continued as sources of infection to innumerable others.

Over half the cases admitted have been returned to active life either cured or near enough cured to resume their occupations.

Outside of Fort Stanton, the larger marine hospitals are located in New York, Chicago, San Francisco, Boston, Detroit, Buffalo and New Orleans.

The second-class stations are under the command of commissioned officers, but have no hospital accommodations of their own. Patients are kept in private or other hospitals, under the exclusive professional care of the medical officer, and the government pays for the hospital facilities under a definite contract. Third-class stations are under the charge of contract acting assistant surgeons, and patients are cared for under government contract with local hospitals. All other relief stations come under the fourth class. Certain of these have a contract surgeon in charge, but have no hospital facilities available, and the

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for Summer, Fort Stanton.

functions of the others are exercised by the Collector of Customs at the place.

Persons entitled to the benefit of medical relief from the Public Health Service are those employed on board in the care, preservation or navigation of any registered or licensed vessel of the United States, or in the service on board of any so engaged.

Officers and crews of vessels in the service of the Mississippi River Commission are included with those entitled to marine hospital relief. This commission has to do with the engineering and inspection of the Mississippi levees, and the removal of snags and obstructions to shipping. Its concern is to maintain the navigability of the Mississippi and its larger branches.

The Revenue Cutter Service., the Army Engineering Corps, together with keepers and surfmen of the Life-Saving Service, are all beneficiaries, as well as the men of the Light House Service, including light ships. A provision not generally known is that foreign seamen may utilize the Marine Hospital accommodations, if written security is given for the payment of the small fees fixed by the department, by the master of the vessel or the consul of the nation under whose flag the vessel sails. In the year ending June 30, 1911, a total of 52,209 patients were treated at the various relief stations of the service, of whom 15,442 received hospital care. At the Fort Stanton Sanatorium, 322 consumptive patients were under treatment.

A large number of physical examinations of seamen in the various government services are necessary, as of candidates for entrance, for promotion and for retirement. Such examinations are conducted by

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Officers' Quarters. Fort Stanton. New Mexico.

Marine Hospital Service officers for the Revenue Cutter, Coast-Survey, Life-Saving and Lighthouse Services. Instruction is given, when properly applied for, in methods of resuscitation of persons apparently drowned. Applicants for a pilot's license are examined as to their hearing, color perception and visual acuity. The total of such physical examinations for the last fiscal year was 4,610.

There are many foreign details filled by service officers besides their varied and extensive activities at home. The American consulates have medical officers attached in Yokohama, Habana, Guayaquil, Naples and Hong Kong. Contract surgeons are kept at the principal ports of China, Russia, Japan, India, Italy, Mexico and tropical America. Eight United States Revenue Cutters have a medical officer on board. Through all these various and widely separated posts, information is constantly being collected and collated as to health conditions all over the world. This information is issued in the Public Health Bulletins published weekly by the Bureau of the Public Health Service in Washington. Service officers are detailed to attend certain congresses and conventions on scientific and medical lines, in this country and abroad, and many exhibits are prepared for scientific and popular conventions, of an educative nature and illustrative of the service work.

No more important feature of national health protection can be named than the quarantine service. The history of quarantine measures takes us back to the time of the Milanese and Lombardians, late in the fourteenth century. At that period the great and lucrative Italian commerce had been responsible for the introduction of the black plague from the Levant into Europe and terrible fear was on all the people. Persons coming in with the plague were taken into the midst of large fields and left alone to recover or die as best they could. The penalty for disobedience of the stringent rules was death and confiscation of the victim's property. In 1475 Venice established a Sanitary Council of three nobles, who were directly charged with preventing the entry of epidemic disease. The Council constructed lazarettoes on two islands, and instituted a rigid inspection of incoming crews, and the letters of health from the place of departure. The time of detention was forty days (quarante diei), hence our term quarantine. Venice was therefore the first to practise systematic quarantine. Similar arrangements were adopted by other countries, and have developed into our modern institution of quarantine. The first quarantine disregarded humane and medical considerations, for the sake of commerce. The latest quarantine disregards commerce but only if it stands in the way of public health and real humanity.

Quarantine stations are maintained at forty-five points of entry into the United States, besides eight stations each in Hawaii, Porto Rico and the Philippines. The quarantine control of the Canal Zone is also exercised by the Public Health Service. A fully equipped quarantine station has adequate provision for boarding and inspecting vessels, apparatus for mechanically cleansing them, and suitable equipment for disinfection with steam, sulphur, formaldehyde and various solutions. It must include a clinical laboratory, hospitals for contagious and doubtful cases, a steam laundry, detention barracks for suspects, bathing facilities, a crematory, sufficient supply of good water and a proper system for the disposal of sewage.

Vessels from domestic ports are also subject to quarantine, if quarantinable disease prevails in the port of their departure, or if there is sickness on board. No persons other than quarantine and customs officers, and pilots, are permitted to board vessels subject to quarantine, until they have been given free pratique. In case a vessel carrying immigrants develops quarantinable disease in transit, after

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Bed Shelter, Hospital Annex, Fort Stanton.

the full quarantine regulations have been satisfied, the health officers of the several states to which the immigrants are bound are notified of the circumstances that they may keep close supervision to detect any later development of the disease.

Those vessels are placed in quarantine which have had quarantinable disease on board in transit or which the inspecting officer considers to be infected, also vessels arriving during the summer months from tropical American ports, which are not known to be free from yellow fever. Vessels in quarantine may have no direct communication with any person or place outside, and no communication of any nature except

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Immigration Station, Pelican Island, Galveston, Texas.

under the supervision of the officer in charge. The persons detained from such a vessel are divided into small isolated groups, and inspected twice daily by the physician. No intercourse is allowed between these groups. No convalescents are discharged from quarantine until free from infection, and whenever possible this is determined by bacteriological examination.

The United States quarantine regulations provide for inspection of but six diseases, yellow fever, typhus fever, bubonic plague, leprosy, smallpox and cholera. A few facts relative to these will make plain the nature of the special precautions necessary to exclude them.

Yellow fever is the great sanitary curse of the tropical Americas. It is an acute non-contagious fever of unknown causation. Its extreme fatality is shown by a death rate which varies from 1 to 95 per cent. The causative agent, whatever it may be, is found in the patient's blood and is transferred to others by one agency alone, a certain type of mosquito, Stegomyia fasciata. The area where yellow fever is endemic corresponds exactly with the geographical distribution of the Stegomyia. It was due to the magnificent work of the Army Yellow Fever Commission in Cuba in 1898 that responsibility for the spread of the disease was definitely laid to the role of this mosquito. Too much honor can not be paid to those brave physicians who risked their lives to discover a means of checking this yellow scourge and above all to Drs. Walter Reed and Lazear, whose lives helped to pay the price for the knowledge which finally vanquished yellow fever. Their associates on the board, Drs. Carroll and Agramonte, as well as Dr. Finlay, of Havana, are no less deserving of praise. The work of the Army board completed the excellent pioneer work of Surgeon Henry E. Carter on the incubative period of yellow fever. It follows that yellow fever can only be successfully combated by destruction of the mosquitoes by means of which it spreads. Quarantine measures against the disease are therefore concerned with isolation of all cases and very careful exclusion of every possible contact with mosquitoes by screening and elimination of all breeding places.

Cholera presents an entirely different picture from the standpoint of quarantine. Here we have a disease proved to be caused by an intestinal infection with a definite and characteristic microbe, the so called "comma" vibrio of Koch. The infection is limited absolutely to the intestinal tract, consequently the entire danger of spread of the disease is limited to the alvine discharges. The bacteria are taken into the system chiefly through the ingestion of infected drinking water, the contamination having arisen from sewage infection or other polluting contact with infected intestinal discharges. Uncooked vegetables and fruits are a secondary source of danger for like reasons. Preventive measures must also be extended to exclude articles of diet such as fresh fruits, for instance, which may tend to excite a tropical diarrhea and so produce a point of lowered resistance where the cholera germs can take effect. Quarantine measures, therefore, aim to isolate all frank cases and suspects, and to detain all who have been exposed, in small groups under close observation for at least five days,' covering the incubation period of cholera. Water and food supply must be above suspicion of carrying the germs, and strict cleanliness of person and quarters must be strictly enforced. It is absolutely essential that intestinal discharges from frank cases and suspects alike be thoroughly disinfected. Before convalescent cases are released from detention the intestinal discharges must be proved free from cholera germs by microscopical examination and bacteriological culture.

Smallpox is more familiar than the diseases just described, as are also the circumstances embodied in its quarantine control. Vaccination or proof of immunity by having had the disease are required of all persons exposed, which, of course, means all on board an infected vessel.

Typhus fever, the old time "ship" or "famine" fever, is very rare now in the United States, probably because of improved ship hygiene and sanitation, conditions always inimical to the disease. The last epidemics in this country were in Philadelphia in 1883 and in New York in 1891-92. Very rarely is a case seen at quarantine, but it is controlled by isolation, and disinfection of articles and quarters exposed to infection. Drs. Anderson and Goldberger, of the Hygienic Laboratory,

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Disinfecting Wharf., Tampa Quarantine Station, Florida.

have recently proved the identity of typhus and "Brill's disease" a disease fairly often seen in large cities. They have also shown the role of the body louse in transmitting typhus. The isolation period for suspects is fourteen days.

No more terrible epidemic has ever threatened this country than bubonic plague and against the entry of no disease are more rigid precautions taken. It exists constantly in oriental countries, especially in China and India, and the great danger of introduction here always confronts us. There are several forms of plague, of which the pneumonic type is the most deadly. This was the prevailing type in the recent epidemic in northern China. The bacillus of plague lives and multiplies in the blood of the victim. It also causes an epizootic in rats and certain other rodents, and from these, as well as from human cases, the bacilli are carried to human victims through the agency of fleas and bedbugs. In addition pneumonic plague is highly infectious directly, spreading from man to man by aerial convection. It is very easily seen how important is the eradication of plague epizootic among rats, ground squirrels and other rodents as is being done now in California. An epizootic is a powder magazine waiting only for the match of proper local conditions to explode in all directions in an epidemic of the greatest virulence.

Quarantine measures against plague first of all aim to prevent infected cargo, baggage or ballast from being shipped. To this end rat guards are used, all suspicious articles going on the vessel are thoroughly disinfected and special efforts are made to destroy all rats on board. Cases of plague reaching a domestic quarantine station are isolated and the surroundings and belongings thoroughly disinfected. A period of fifteen days must elapse after the last possible exposure before release of suspects.

Leprosy is only mildly contagious, at least in this country, and is an instance of a disease made quarantinable more because of its loathsome nature and the abhorrence in which it is popularly held than because of actual infective danger from it. The immigration law absolutely excludes all alien lepers. Others must be removed from vessels at quarantine, and the quarters disinfected.

No small feature of the activity of the Public Health Service is its conduct of the medical examination of immigrants. No argument is necessary to convince every thoughtful patriot of the vital importance of this work. The immigration laws are explicit, and while the medical examiners have no authority to pass judgment on the admissibility of aliens, they have the basic function of supplying medical evidence against mental and physical defectives, which evidence under the law has a determining influence with the inspectors of the Immigration Bureau of the Department of Commerce and Labor. The methods of medical inspection of incoming aliens and laws concerned, have been discussed and described by the author elsewhere,[2] and will not be taken up here.

By far the largest port of entry for immigrants is through Ellis Island, N. Y. During the year ending June 30, 1911, 749,642 aliens were inspected there, as against a total of 303,007 for all other points of entry combined. At Ellis Island are stationed 23 medical officers,

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Quarters at Tampa, Fla.

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Detention Barracks, Marivales Quarantine, Philippine Islands.

and a larger force would be able to do even better work. The immigrant hospital on Ellis Island during the year mentioned cared for 5,141 aliens, in addition to 720 cases of acute contagious disease which were transferred to the State Quarantine Hospital at the entrance to the harbor pending completion of the present excellent contagious disease hospital on Ellis Island. There is possibly no place in the United States where a similar variety of interesting and unusual cases can be seen as at the Ellis Island Immigrant Hospital. Drawn from every race, nation and climate, one can see there all the usual varieties of disease and, in addition, peculiar tropical affections, unusual skin lesions and obscure internal disorders of the most diverse description. This hospital is excellently conducted and reflects credit on the professional skill of the officers in charge, as well as being a godsend to the immigrants who constitute its sole source of patients.

Next to Ellis Island the larger immigration points are Boston, with 45,865 entries; Philadelphia, with 45,023; Baltimore, with 22,866; and then San Francisco, Galveston, Seattle, Honolulu and Tampa. Medical examination of incoming aliens is conducted at forty-five points besides the preliminary advisory, inspections made by medical officers detailed to consulates in foreign countries.

The annual report of the surgeon general for the last fiscal year contains an account of many valuable and interesting lines of investigation conducted by service officers. One of the most notable achievements was the transmission of measles from man to monkeys, the first time this has ever been accomplished. Contrary to the erroneous popular belief, measles is one of the most fatal of common diseases, largely because of complications. Ability to produce it experimentally in animals opens the way for the discovery of the causative agent, as well as of a curative or prophylactic serum.

Assistance has been given to the Bureau of Chemistry of the Agricultural Department by officers of the Hygienic Laboratory in the scientific investigation of certain food products, and in giving testimony in court in trials arising under the Pure Food and Drugs Act. About one hundred proprietary medicines have been examined as to composition, strength and action.

Treatment for rabies was successfully administered to 128 persons, and 777 treatments were sent out into 14 different states. Examinations are made at the Hygienic Laboratory for tuberculosis in government employees. At the request of state authorities, officers have been detailed to determine the cause of the prevalence of typhoid fever in several states. A sanitary survey has been made of towns bordering on Lake Erie and the Niagara River and the work is being continued on all of the Great Lakes to collect data relative to their contamination with typhoid germs. The results will be applied directly to the prevention of sewage pollution, and the conservation of a pure water supply in those communities dependent for their supply on the Great Lakes.

Much work has been done on the subject of pellagra and patients

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Disinfecting Wharf and Bathhouse, Marivales Quarantine Station, Philippine Islands.

with this disease have been admitted to the Marine Hospital at Savannah for special observation and study. Similarly patients have been admitted to the Wilmington, N. C, Marine Hospital for the study of hookworm infection. Two laboratory officers were detailed with the mine rescue car of the Bureau of Mines to investigate hookworm disease among miners in southern states and lung diseases among Colorado miners, and also to report on the general sanitation and hygiene of mines.

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Service Quarters, Marivales Quarantine, Philippine Islands.

The San Francisco plague laboratory has continued its work of examining rodents for the germs of bubonic plague. It has also made studies on the penetrating power of various gases used in disinfecting ships, on rat leprosy and on the role of fleas in transmitting the plague. At the Leprosy Investigation Station in Hawaii, the bacillus of leprosy has been successfully grown on artificial media. Monkeys have been inoculated with leprosy from human beings, and thus the way has been opened for the development of a curative or preventive serum. Special studies have also been made by service officers on such subjects as the sanitary disposal of night soil; the growth of animal tissues outside the body; the role of oysters in the propagation of typhoid fever; the longevity of the typhoid bacillus on vegetables; and the influence of poisonous gases on health.

During the summer of 1912, plague broke out in Porto Rico and Passed Assistant R. H. Creel was detailed to direct the work of control and eradication. In all five officers were engaged in the duty and the outbreak was limited to a small section. As at San Francisco, special emphasis was placed on rat eradication and the rat-proofing of buildings and docks. A general clean-up and enforcement of sanitary measures have been instituted. What might have been a situation full of deadly peril for this country was averted by the prompt and effective work of the service.

The report of the Secretary of the Treasury for the fiscal year of 1911 presents an optimistic picture of the operations of the Public Health Service and recommends certain features which should be further encouraged. Attention is called to the necessity of enlarging

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Isolation Hospital, Cebu Quarantine, Philippine Islands.

the available fund for fighting epidemic disease. There should be ample provision for emergency measures which may be necessitated at any time by the sudden appearance of epidemic disease, before there is time for Congress to pass special appropriation legislation. Special appropriations are requested for the investigation of pellagra, a disease of serious menace which is spreading widely in the United States, and which threatens to become endemic at terrible cost in lives and money, as it has already done in Italy. Another building is required for the Hygienic Laboratory to provide more room for special researches, disinfection experiments and the housing of small laboratory animals. The secretary invites particular attention to the "Personnel Bill" designed to make the pay of Public Health Service officers equal to that of the Army and Navy Medical Corps. This hill was passed by the Senate and reported favorably and unchanged to the House by the Committee on Interstate and Foreign Commerce. Every argument strongly favored its passage. As stated by Mr. Fletcher in the report of the Senate Committee on Public Health and National Quarantine, when the bill was before the Senate:

In the opinion of the Committee, there exists no such difference in the character of the duties performed and responsibilities assumed, the hazards to which the officers are exposed, or the professional and scientific attainments required in the several services, as to warrant the existing disparity in compensation.

The committee recommended the bill to the Senate, "believing that the maintenance of the present efficiency of the Service, as well as justice to its officers, demands the equalization of pay proposed by the bill." This bill in an amended form, passed congress and was approved by the President on August II, 1912. It provided for increased salaries, and changed the name from the Public Health and Marine Hospital Service to the more accurate and less cumbersome title, the Public Health Service. The public health functions and duties of the Service were extended. "The Public Health Service may study and investigate the diseases of man and conditions influencing the propagation and spread thereof including sanitation and sewage and the pollution either direct or indirect of the navigable streams and lakes of the United States and it may from time to time issue information in the form of publications for the use of the public."

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Quarters of Medical Officer, Cebu, Philippine Islands.

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Office of the Public Health Service, Kobe, Japan.

On January 13, 1912, the Senate confirmed the President's appointment of Dr. Rupert Blue to succeed the late Dr. Wyman as surgeon general. Dr. Blue is a comparatively young man, but comes to this responsible post well prepared and with prospects bright for an administration strongly conducive toward maintaining the present high standard of the Public Health Service in personnel and efficiency, and increasing its prestige and value to the nation.

Dr. Blue was born in South Carolina in 1868, graduated from the University of Maryland in 1892, and was commissioned an assistant surgeon in the Marine Hospital Service the following year, after serving an interneship in a Marine Hospital. Four years later he passed the examination for passed assistant surgeon. He attained the rank of surgeon on May 1, 1909. His first eight years in the service were spent in the usual round of routine duties at various points in the United States. In 1903-04 Dr. Blue was detailed as executive officer under Surgeon Joseph H. White, who was in charge of the operations directed toward the eradication of bubonic plague in San Francisco. The following year he assisted in the suppression of yellow fever in New Orleans. At the Jamestown Exposition in 1907 Dr. Blue was made director of sanitation and showed ability above the ordinary in organization and in reconciling the various interests represented at the exposition and making a conspicuous success of its sanitation. He went from Jamestown to San Francisco, where the plague had reappeared, where lie handled the situation admirably, allaying friction and working in noteworthy harmony with the municipal and state officers. Later he spent some time in Europe, studying emigration, preventive medicine and quarantine management. In May, 1910, Dr. Blue was detailed to represent the service at the International Congress on Medicine and Hygiene at Buenos Ayres, and took advantage of the opportunities

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Surgeon-General Rupert Blue.

there offered to study possible routes by which yellow fever and plague might be imported into the United States.

The last detail before he became surgeon-general was in Honolulu, where he was sent to act in an advisory capacity to the Hawaiian board of health and other branches of the territory government in carrying out a sanitary program designed to decrease to the smallest possibility danger of invasion by yellow fever or bubonic plague after the opening of the Panama Canal, and to make their spread impossible, if introduced. The appointment to the surgeon-generalship made necessary the assumption of this work by Passed Assistant Surgeon McCoy, who thus takes up the role of adviser to the Civic Sanitation Committee of Hawaii. This committee is particularly concerned with perfecting sanitary measures to prevent propagation of disease-bearing insects and rodents, and its work is being carried on in conjunction with the territorial board of health.

Dr. Blue has always been especially strong in the field of preventive medicine and quarantine, rather than in the line of hospital service. He is a man of engaging personality, an excellent executive, a skillful organizer and judge of men, and above all, he has in full measure the happy quality of making friends and reconciling opposing interests.

The Public Health Service stands to-day on its record and its aspirations, a monument to the men who have made it, a memorial to the gallant officers whose lives have been laid down in devotion to their duty and the principles of their corps, and the strong bulwark of the American people against the deadly foreign foes of epidemic disease, and the insidious domestic perils of poor sanitation, ignorance and prejudice.

Of more vital though prosaic importance to the nation than either army or navy, it has been less generally known and its work less completely understood. But this is rapidly being changed as the great wave of enlightenment and interest in public and national health affairs sweeps over the country, and as the knowledge is slowly increasing that prevention of disease is the primary and essential work of the physician.

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  1. The author is indebted to Surgeon George W. Stoner, Chief Medical Officer at Ellis Island, for many facts concerning the earlier history of the Public Health and Marine Hospital Service.
  2. "Medical Aspects of Immigration," The Popular Science Monthly, April, 1912; "Going through Ellis Island," The Popular Science Monthly, January, 1913.