pan american sanitary bureau: annual report of the...

PAN AMERICAN SANITARY BUREAU

OFICINA SANITARIA PANAMERICANAPUBLICATION No. 176 * APRIL, 1942

Pan American Sanitary Bureau:

Annual Report of the Director

Fiscal Year 1940-41

WASHINGTON, D. C.U. S. A.

FUNCIONARIOSDE LA

OFICINA SANITARIA PANAMERICANA

(OFFICERS OF THE PAN AMERICAN SANITARY BUREAU)

DIRECTOR

DR. HUGH S. CUMMINGSurgeon General (Retired), U. S. Public Health Service

VICEDIRECTORDR. JoXo DE BARROS BABRETO

Brasil

CONSEJEROS (COUNSELORS)

DR. MIGUEL SUSSINI

Argentina

DR. ANTONIO PEÑA CHAVARRÍACosta Rica

DIRECTOR AUXILIAR (ASSISTANT DIRECTOR)

DR. EDWARD C. ERNSTServicio de Sanidad Públiea de los Estados Unidos

SECRETARIO (SECRETARY)

DR. ARÍSTIDES A. MOLLRedactor Cientfico, Boletin de la Oficina Sanitaria Panamericana

VOCALES (MEMBERS)

DR. ATILIO MACCHIAVELLOChile

DR. LUIS MANUEL DEBAYLENicaragua

DR. A. L. BRICEÑO ROSSIVenezuela

DR. DAGOBERTO E. GONZÁLEZPerd

DR. MANUEL MARTINEZ BÁEZMézico

DR. PEDRO MACHADOCuba

DR. JUAN ANTONIO MONTALVÁNEcuador

MIEMBROS DE HONOR (HONORARY MEMBERS)

DR. JORGE BEJARANO, Presidente de HonorColombia

DR. CARLOS ENRIQUE PAZ SOLDÁNPerú

DR. LUIS GAITÁNGuatemala

COMISIONADOS VIAJEROS(TRAVELING REPRESENTATIVES)

DR. JOHN D. LONG

DR. JOHN R. MURDOCK

DR. ANTHONY DONOVAN

DR. HENRY HANSON

DR. VERNON W. FOSTER

DR. JOSEPH S. SPOTO

INGENIEROS SANITARIOS(SANITARY ENGINEERS)

SR. EDWARD D. HOPKINS

SR. WALTER N. DASHIELLSR. WILLIAM BOAZ


OFICINA SANITARIA PANAMERICANAPUBLICATION NO. 176 * APRIL, 1942

Pan American Sanitary Bureau:

Annual Report of the Director

Fiscal Year 1940-41

WASHINGTON, D. C.U. S. A.

TABLE OF CONTENTS

Introduction ................................................ 3Personnel ................................................... 4Continued Expansion ........................................ 5Space ...................................................... 5Organization ................................................ 5Directing Council ............................................ 6Pan American Health Day .................................... 6Committees ................................................. 7Caribbean Conference ........................................ 8Other Meetings ............................................ 8Public Health Progress ................... 8................... 8Scholarships and Fellowships .................................. 10Cooperation with the Coordinator of Inter-American Affairs ...... 12Water Supplies of Quito and Guayaquil ........................ 12Pharmacopeia ............................................... 13Colombian Sanatorium ........................................ 13Poliomyelitis in Chile ........................................ 13General Field Activities ..................................... 14International Epidemiology ................................... 19Other Epidemiological Developments .......................... 33Bulletin .................................................... 35Inquiries (Consultas) ......... : ............................... 36Library ................... ................................ 37Microfilm Service ................... ........................ 38Biologic Standards ................... ........................ 39Finances ................... .............................. 39

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ANNUAL REPORT OF THE DIRECTOR OF THE PANAMERICAN SANITARY BUREAU

1940-41

INTRODUCTION

I am submitting below the report of the activities of the Pan AmericanSanitary Bureau during the fiscal year 1940-41, this being the 39thyear of the creation of the Bureau and the 21st year since I first becamedirector in 1920.

It is only proper to begin my remarks by expressing my sincere thanksand appreciation to the members of the Directing Council of our Bureauas well as to all the national health authorities of the American Re-publics for their continued and invaluable assistance.

It is also most fitting that a special acknowledgment should be madeto the Pan American Union, particularly to its Director General, forthe cooperation and assistance which they have so freely given. With-out the increased office facilities made available by the Union, theBureau would have been seriously handicapped, and many of ouractivities would of necessity have suffered.

HUGH S. CUMMING

Director, Pan American Sanitary Bureau

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4 ANNUAL REPORT OF THE DIRECTOR

PERSONNEL

The personnel of the Pan American Sanitary Bureau, as elected atthe Tenth Pan American Sanitary Conference, continues to be as follows:

DIRECTOR ................................ DR. HUGH S. CUMMINGWashington, D. C.

VICE DIRECTOR ......................... DR. JOXo DE BARROS BARRETORio de Janeiro, Brasil

COUNCILLORS ............................. DR. MIGUEL SUSSINIBuenos Aires, Argentina

DR. ANTONIO PEÑA CHAVARRÍA

San José, Costa Rica

ASSISTANT DIRECTOR ................... DR. EDWARD C. ERNST*Washington, D. C.

SECRETARY and EDITOR ................. DR. ARfSTIDES A. MOLLWashington, D. C.

BUREAU MEMBERS ....................... DR. ATILIO MACCHIAVELLOSantiago, Chile

DR. LuIs MANUEL DEBAYLE

Managua, NicaraguaDR. A. L. BRICEÑO ROSSI

Caracas, VenezuelaDR. DAGOBERTO GONZÁLEZ

Lima, PerúDR. MANUEL MARTINEZ BÁEZ

México, D. F.DR. PEDRO MACHADO

Habana, CubaDR. JUAN ANTONIO MONTALVÁN

Guayaquil, Ecuador

HONORARY MEMBERS .................... DR. JORGE BEJARANOHonorary PresidentBogotá, Colombia

DR. CARLOS ENRIQUE PAZ SOLDÁN

Lima, PerúDR. JUSTO F. GONZÁLEZ

Montevideo, UruguayDR. LUIS GAITÁN

Guatemala

TRAVELING REPRESENTATIVES* ....... DR. JOHN D. LONGDR. JOHN R. MURDOCKDR. ANTHONY DONOVAN

DR. HENRY HANSON

SANITARY ENGINEERS* ................. MR. WILLIAM BOAZMR. EDWARD D. HOPKINS

*Appointed by the Director.


CONTINUED EXPANSION

The Pan American Sanitary Bureau completed its 39th year ofexistence on June 30, 1941. This date also marked its 21st year ofoperation since the present Director was first elected in 1920. Thegrowth of the Bureau, already most definite and clearly outlined duringthe last two years, may be justly said to have been enormously ac-celerated during the fiscal year reviewed in this report. There has beennaturally some dfficulty in adjusting and developing the necessarymachinery for handling such increased activities. This, however, hasbeen gradually accomplished, thanks largely to the public spirit, willing-ness and competence of the staff.

SPACE

Not the least of problems has been that due to the lack of adequatespace to house the growing number of employees. So far no practicalsolution has been found, although different possibilities continue to beweighed and explored.

ORGANIZATION

The work of the Bureau continues to be conducted under the guidanceof the Director and Assistant Director, and the immediate supervisionof the Secretary, in conformance with the classification of functionsdescribed in the last Annual Report, which is as follows:

Editorial (including especially the publication of the Bulletin and transac-tions of the Conferences)

Epidemiology and Vital StatisticsLegalLibraryTranslatingAccountsDistribution of PublicationsFiles

The small staff and increased work have made it advisable, as hereto-fore, to combine various activities into one section.

In addition to the Director, the Assistant Director, and the Secretary,the central office staff in Washington included at the end of the fiscalyear: 1 legal assistant, 1 editorial assistant, 1 statistical assistant,1 librarian, 8 translators and stenographers, 1 file clerk, 1 assistantlibrarian, and 1 messenger. Some of the stenographic personnel are,however, employed on a temporary basis. At the present time thefollowing countries are represented in our office staff: Argentina, Brazil,Cuba, Mexico, Panama, the United States, and Venezuela.

During the fiscal year the field personnel has included 5 permanentand 3 temporary traveling representatives, 3 sanitary engineers, and 1epidemiologist.

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ANNUAL REPORT OF THE DIRECTOR

DIRECTING COUNCIL

On more than one occasion I have had the opportunity to utilize,in an advisory capacity, the services of different members of the Direct-ing Council. Their assistance has invariably proved most valuable.It is a matter of deep regret to me that the large distances to be coveredand the difficulty which some of these members find in separating them-selves from their offices make it impracticable for the entire Council toconvene more frequently to discuss the important problems which areconstantly arising and affect all our countries.

I can not help but repeat previous observations as to the desirabilityof the 1 lth Pan American Sanitary Conference acting on the suggestionsthat the designation of the different members should, in each case, beleft to the authorities of the countries to be represented on the Council.This would insure actual official representation and prevent any awk-ward situations which might arise when members have ceased to beconnected with their respective governments.

PAN AMERICAN HEALTH DAY

The complete unanimity and enthusiastic participation which markedthe celebration of Pan American Health Day throughout the WesternHemisphere are a tribute both to continued solidarity and recognitionof the importance of public health work. Decrees were issued in all theAmerican Republics proclaiming December 2 as Pan American HealthDay, not only for 1940, but for every year thereafter.* All the Ameri-can Republics responded with sincere demonstrations of their faith inpublic health as a safeguard for the present and the future citizens ofthe Americas. The significance of the occasion was emphasized by thepersonal participation of the chief executives as well as professional andlaymen in most of the countries.

The Pan American Sanitary Bureau issued a special edition of theBulletin in honor of the Day. The ceremonies in the various countriestook diverse forms: tributes to the pioneers in public health work byvisiting the tombs of the dead, conferring of decorations upon livingsanitarians and unveiling plaques in their honor, issuing special seriesof postage stamps, opening of health centers and hospitals, conductingreligious ceremonies, radio programs, receptions, special sessions ofmedical societies, inviting the people to visit health offices, offering freemedical consultations to the public, and exchanging greetings and pledgesof continued cooperation between the members of the profession through-out the continent.

*The celebration of an annual Pan American Health Day was recommended by the IV PanAmerican Conference of National Directors of Health, and the date, anniversary of the first PanAmerican Sanitary Conference, was selected after consultation with the Latin American Healthauthorities.

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PAN AMERICAN SANITARY BUREAU 7

This, the first Pan American Health Day, proved a heart-warmingdemonstration of cooperation and unanimity of purpose. There is littledoubt that the future will see an even more universal participation inthe great inter-American festival dedicated to health and hygiene.

COMMITTEES

Nutrition.-The membership of the Pan American Committee onNutrition consists of: Dr. E. V. McCollum, Chairman, Dr. Justo F.González, Dr. Pedro Escudero, Dr. Jorge Mardones and Dr. W. H.Sebrell. Other names will eventually be added. The Committee hasto date limited its activities chiefly to the preliminary preparations forits report to the XI Pan American Sanitary Conference.

However, one project directly connected with the work of the Com-mittee is the publication of a handbook on bromatology prepared at theSchool of Tropical Medicine of Puerto Rico. This publication will makewidely available for the first time in Spanish a mass of information on alarge number of foods commonly used in the tropics, the data beingmostly taken from U. S. publications but also including the results ofsome original research.

Committee on Malaria.-The Pan American Committee on Malariaincludes the following members: Dr. L. L. Williams, Dr. Henry Hanson,Dr. Mark F. Boyd, Dr. C. A. Alvarado, Dr. Joao de Barros Barreto,Dr. Víctor A. Sutter, Dr. Luis Vargas, and Dr. Arnoldo Gabaldon.When Dr. Williams was called to other duties, Dr. Gabaldón assumedthe chairmanship of the committee (On April 24, 1941). The work ofthe committee has included: (1) The appointment of three sub-com-mittees to study the suggestions of the Director of the Pan AmericanSanitary Bureau (Sub-committee on Malaria Research, Subcommitteeon Entomology, Subcommittee on Anti-Malaria Drugs); (2) Studies onthe anopheles mosquito, already started in Argentina, Bolivia, Peru, andthe Dominican Republic; and (3) Preparation of a questionnaire inwhich every country will have an opportunity to present all data con-cerning its malaria problems.

Public Health Code.-The Pan American Committee on PublicHealth Code includes the following members: Dr. Joao de BarrosBarreto, Dr. A. de la Garza Brito, Dr. C. E. Paz Soldán, Dr. Mario J.LeRoy, Mr. Gregorio Márquez, Secretary. A draft of a model codehas been prepared by the Secretary for submission to the differentmembers. It will undoubtedly require long consideration in view of themany factors and different conditions to be taken into account. It ishoped, however, that a tentative memorandum on some parts may beready for presentation at the XI Pan American Sanitary Conference.


CARIBBEAN CONFERENCE

The Secretary of the Bureau, Dr. Arístides A. Moll, was detailed toattend the third meeting of the Inter-American Caribbean Union atPort-au-Prince, Haiti, on April 2, 1941. At this Conference rather im-portant resolutions were adopted favoring closer cooperation in healthmatters among the various countries concerned, and the use of thefacilities of the Pan American Sanitary Bureau for such purposes.

OTHER MEETINGS

The Secretary of the Bureau also presented a paper.at the ninthannual meeting of the Population Association of America at Princeton,New Jersey, May 16, 1941; and has given on a number of occasions,before different organizations, talks on the work of the Bureau andmedical and health conditions in Latin America.

Representatives of the Bureau also attended other important meet-ings and conferences as follows: Pan American Congress on Tuberculo-sis, Buenos Aires and Cordoba, October, 1940, Drs. Gregorio AráozAlfaro and Henry Hanson; Pan American Red .Cross Conference atSantiago, Chile, December 3-15, 1940, Drs. J. D. Long and F. R.Brunot; Meeting of Social Security Administrators, Lima, December,1940, Dr. Anthony Donovan; Directing Council, International AmericanChild Welfare Institute, Montevideo, February, 1941, Dr. F. R. Brunot;Pan American Endocrinological Congress, Montevideo, March, 1941,Dr. E. L. Severinghaus; Conference of State Directors of Health ofBrazil, Sao Paulo, April, 1941, Dr. F. R. Brunot.

PUBLIC HEALTH PROGRESS

One of the most encouraging developments during the last year hasbeen the effort made throughout all our Republics to maintain previoushealth achievements and protect, in spite of a rather unfavorable finan-cial situation, the health of the people. Signs of this endeavor may befound in the opening of new hospitals and health units and improve-ment of old institutions, on a national scale. An instance to the pointis the inauguration of the new National Institute of Health at Guayaquil.

A most encouraging feature has been the increasing attention givento one of the fundamentals of public health: safe water supplies. InMexico the Government is sponsoring a far-reaching program with aspecial fund, a national drinking water division having been created inthe National Department of Health. From 1934 to 1941 water serviceswere either improved or installed for the first time in 337 small towns.A bill introduced in the Congress authorizes a large loan to be used for afurther development of this plan. Similar work is being planned inVenezuela, and plans for water works and sewerage for Caracas havealready been approved. In Colombia a Municipal Improvement Fund

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was created in March, 1940, which has already completed 140 watersystems and 10 sewerage systems. A new water supply system forBogotá has also been recently placed in operation. In Uruguay theDivision of Sanitation in charge of this work by 1940 was supervising104 water supplies and 18 sewerage services. In Costa Rica a recentlaw places the control of all municipal water supplies in the countryunder the Department of Public Health.

Dr. J. D. Long, Senior Traveling Representative, has also em-phasized the same point in the following words: "Radical improvementshave been made in Peru in the water supply of the City of Lima andother interior cities, and also in Ecuador in the Cities of Quito andQuayaquil. In Chile studies of water supplies in the cities of Santiagoand Valparaiso have been carried out, and in Paraguay, of the Asunciónwater supply. In the Argentine and Uruguay there is a continuouswater program underway under the direction of their Departments ofPublic Works. In Brazil much progress is also being made, especiallyin the City of Rio de Janeiro. Sewage disposal is progressing also as acorollary to improvement in water supplies." Field representatives ofthe Bureau have assisted in a number of these activities as may be seenelsewhere.

It is again most gratifying to place on record the fact that all importantsea and air ports remain free from disease, facilitating uninterruptedcommunications between the American Republics. This is of singularimportance at the present time because the shipping shortage haspressed into service vessels in poor sanitary condition or vessels with ameager sanitary history which come to port without previous notice oftheir point of origin or date of arrival. In addition, the exigencies ofwar have resulted in a lax observance of sanitary measures aboardships as well as at many ports of departure. The spread of typhusfever in certain European countries and its recent recognition insome American Republics has naturally attracted attention. Becauseof the extension of aerial navigation to the west coast and the interiorof Africa, the possible introduction of yellow fever and other diseasesprevailing in that continent must receive serious consideration. It hasbeen brought out recently that in anticipation of these problems effectivemeasures are being taken to prevent maritime introduction of majorquarantinable diseases, particularly plague and typhus. Such pre-cautions are in accordance with the International Sanitary Conventionof 1926, as well as the Pan American Sanitary Code of 1924, wherebyeach country has the right to apply such additional measures as areneeded. The Pan American Sanitary Bureau will continue to advisethe national health authorities as expeditiously as necessary of any newdevelopments which might be of interest to them.


SCHOLARSHIPS AND FELLOWSHIPS

Recognizing the value of exchange students as an effective means forstrengthening the bonds among the American Republics, the PanAmerican Sanitary Bureau sometime ago inaugurated a system ofscholarships and internships available to doctors and other profes-sionals recommended by the national health authorities of the Americanrepublics. Steps have also been taken from time to time to assistnurses, physicians and public health personnel in securing trainingfacilities in the United States. These activities have the sanction of thePan American Sanitary Code, signed in Habana in 1924, and were en-dorsed by the second Pan American Sanitary Conference of NationalDirectors of Health in Washington, in 1931. In 1939 the program wasextended to include internships being granted to six young Chileandoctors in hospitals of the United States Public Health Service. Anappropriation made available in 1940 by the Congress of the UnitedStates permitted the awarding of 22 scholarships to the followingrepublics: Argentina (2), Bolivia (1), Brazil (2), Chile (1), Colombia (3),Costa Rica (1), Cuba (1), Ecuador (3), Guatemala (2), Haiti (1),Honduras (2), Mexico (2), and Perú (1). In addition to general medicineand surgery these fellowships embrace bacteriology, obstetrics, pedi-atrics, dentistry, cancerology, nursing and sanitary engineering.

Some time in 1941, Dr. G. M. Mackenzie of the Mary ImogeneBassett Hospital at Cooperstown, New York, suggested that placesmight be found for a much larger group of young Latin Americanmedical graduates to serve as interns or externs in American hospitals.He volunteered to investigate the possibilities, and when the surveywas completed the matter was discussed with the Office of the Co-ordinator of Inter-American Affairs and a definite plan of action wasadopted. Through the Bureau's contacts with national health authori-ties and the services of its field representatives, a group of 43 younggraduates from the different Republics has been selected and will bebrought to this country early in the next fiscal year. Their travelingand living expenses will be borne by the Office of the Coordinator. Theinstitutions cooperating most actively were: Albany Hospital; ColumbiaUniversity (Presbyterian Hospital); Cornell University (New YorkHospital); Harvard University; Massachusetts Eye and Ear Infirmary,Massachusetts Department of Public Health, and Massachusetts Gen-eral Hospital; Johns Hopkins Medical School and Hospital; LouisvilleCity Hospital; Medical College of Virginia (Richmond); New YorkUniversity (Bellevue Hospital; University of Wisconsin General Hos-pital; Washington University, St. Louis, (Barnes Hospital); Yale Uni-versity (New Haven Hospital); Most of these institutions were mostgenerous in making facilities available. It is really inspiring to seesome of the leading physicians in the United States taking a personal


interest in the matter, and helping their young confreres from LatinAmerica find their way in a new environment.

In a paper entitled "American Hospitals and Latin American Interns"(Hospitals, Sept., 1941, p. 32) the Secretary of the Bureau reviewedsome of the problems that have arisen in the development of the program.Latin American doctors who come to the United States for post-graduatetraining and research usually have served their internship and are readyfor posts as resident physicians. While they cannot, as a rule, expectto fill or receive such posts, it seems in many cases to be a waste oftheir time and ability to again perform the routine duties of an intern.They wish to secure specialized training in some branch of medicineand surgery and to learn the newer American medical and hospitalsystems. A special position as "extern" or "clinical clerk" wouldappear to serve their needs most advantageously. Special trainingcould be given to those coming from less well-equipped schools whoseprevious preparation shows some deficiencies. Another difficulty theseyoung men experience is the difference in language. While English isnow being taught more widely in Latin America, it is difficult even forthose who have a fluent reading knowledge to keep up with lectures andoral instruction. However, it was a real pleasure to see how many ofthe candidates spoke English quite well. This was a most encouragingsign, and it naturally resulted in their being able to start profiting im-mediately by their stay in the United States, in contrast to those whohad first to secure a greater mastery of the language.

Some of the leading hospitals in the United States have been usingLatin American interns and externs during the past several years, someof whom have come on scholarships, and others at their own expense orat the expense of their Governments. Because of the very unfavorablerate of exchange, however, these last two groups are in the minority.

There are three classes of scholarships offered by the Bureau: publichealth, medical, and special (in allied sciences), particularly to membersof the health and medical services of the American Republics. Anapplicant must satisfy the following requirements: be a citizen by birthof an American Republic; have completed his professional training inhis own country, and on coming to the United States, select preferablycourses that are not offered in his own country; be recommended by theauthorities of the University at which he studied, have a health certifi-cate and a chest film; a thorough knowledge of the English language;agree to return to his country on completion of his fellowship; and havethe approval of national health authorities of his country. Scholarshipsare offered for varying periods, but never exceed one school year ortwelve months of study or research. The applications should be sub-mitted to the Secretary of State of the United States through the Chiefof the Diplomatic Mission of the United States in the country of theapplicant, on the forms provided therefor.

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It is expected that in the next fiscal year the number of scholarshipswill be about 60 and embrace practically every American Republic. Itmay be noted that in addition to the United States, a number of otherAmerican Republics are offering scholarships to citizens of their sistercountries. Word to that effect has been received from Argentina, Chile,Cuba, Mexico, Panama, and Venezuela.

The Pan American Sanitary Bureau sees in the scholarship plan amost effective means both for furthering understanding and good willamong the American Republics and for the exchange of scientific data.The unselfish purpose and community of interests and ideals crystallizedby such fellowships offer an excellent basis for cementing bonds offriendship and promoting a better acquaintance.

With regard to scientific interchange in general, it is of interest torecord that over 100 Latin American physicians visiting in the UnitedStates got in touch with the Pan American Sanitary Bureau during thefiscal year.

COOPERATION WITH THE COORDINATOR OFINTER-AMERICAN AFFAIRS

The usual cordial relations have been continued with other agencies(in addition to the public health services) in the different Republicswhich are carrying out work along similar or parallel lines, including theDivision of Cultural Relations of the U. S. Department of State. Re-cently a number of cooperative projects have been undertaken with theOffice of the Coordinator of Inter-American Affairs. As mentionedelsewhere, arrangements have been made with this government agencyto bring the United States a large group of recent medical graduates andalso a smaller group of health officials for additional training at variousinstitutions. The Office of the Coordinator has also agreed to assistin the printing of a manual of bromatology and in making available thefacilities of the medicofilm and microfilm service of the United StatesArmy Medical Library to a number of outstanding research institutionsin Latin America. Other projects of a similar nature are now underconsideration. Several reasons have led the Bureau to enter some ofthese fields, mainly, their manifestly beneficial character, the fact thatthey involved no drain on its funds, and finally the fact that the informa-tion in its possession and field relations admirably fitted the Bureau toact as liaison agency in such cases.

WATER SUPPLIES OF QUITO AND GUAYAQUIL

At the request of the Export & Import Bank of Washington, arrange-ments were made with the U. S. Public Health Service to have SanitaryEngineer T. E. De Martini make, in January-February 1941, in co-operation with Sanitary Engineer E. D. Hopkins, a complete study of

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the Guayaquil and Quito public water supplies. Full reports withrecommendations and estimates for each of these proj ects were submittedon completion of the work.

PHARMACOPOEIA

Publication in Spanish of the second series of articles on "The Phar-macopoeia and the Physician" has been continued in the Bulletin.When the series is completed, it is expected to have it again collectedinto a volume, as the material undoubtedly has permanent value for thepractising physician who wishes to have at hand reliable informationon drugs and their use in treatment. The Bureau has also assisted inthe translation into Spanish of the II Supplement to the U. S. Phar-macopoeia and has offered its aid again in the translation into Spanishof the new edition of the Pharmacopoeia, to appear in 1942.

COLOMBIAN SANATORIUM

The Colombian Authorities having requested through the Ambassadorin Washington assistance in drawing up plans for a tuberculosis sana-torium in Bogota, the Bureau appointed Dr. Kendall Emerson, theManaging Director of the National Tuberculosis Association of theUnited States and Dr. Esmond R. Long of the Phipps Institute inPhiladelphia, to aid in the work. Dr. Long volunteered his serviceswithout remuneration and left on June 4 to make a study of the situationon the actual ground, preliminary to preparing a report.

POLIOMYELITIS IN CHILE

At the request of the National Authorities Dr. Murdock was sent toChile in April 1941 to study the poliomyelitis situation in the northernpart of the country. Dr. Murdock remained in Chile from the 9th tothe 15th of April. His study was made in conjunetion with Dr. Leo-nardo Guzmán, National Director of Health at the time, and Dr. J.Castillo Francke, Provisional Director of Health of Antofagasta, thefollowing places being visited: Pedro de Valdivia, Maria Elena andCecilia, nitrate plants, and Chuquicamata, a copper mine. Twelve oldand eleven recent cases were located and examined. The infection hasobviously been present in the region for a number of years, as shown byresidual cases of flaccid paralysis.

During the examinations Dr. Murdock indicated the treatment forthe individual cases and explained the rules to be followed in treatingany cases which developed in the future. General precautionary meas-ures were also discussed. It was impossible for him to determine wherethe outbreak started and how it spread from one camp to another. Inso far as the author knows, no outbreak of poliomyelitis has ever beendescribed from any part of the globe as dry as it is in the Pampa of

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Antofagasta. The points which seemed of particular interest about theoutbreak may be summed up as follows with conclusions: 1. This is asection of the world which has little contact with other parts of theworld; there were no known cases of poliomyelitis among adults.2. Many of the animals and insects common to other parts of the worldare not found in this desert region. 3. The majority of the twelve acutecases described were benign and there were no severe cases or knowndeaths from the disease. 4. Does the dry climate tend to influence theamount and type of nerve involvement in poliomyelitis? 5. Would it beworth while to treat a number of cases of poliomyelitis under controlledconditions simulating the atmospheric conditions in the Pampa ofAntofagastas? (In rooms where the temperature and humidity could becontrolled, especially the moisture content of the air.) 6. Would it beworth while to experiment with monkeys artificially infected with thevirus of poliomyelitis, confining them in air conditioned rooms to simu-late atmospheric conditions encountered on the Pampa of Antofagasta?

GENERAL FIELD ACTIVITIES

Senior Traveling Representative John D. Long continued during theyear in general charge of field activities. All countries represented inthe Bureau were visited by the field representatives during the fiscalyear. The Western Hemisphere has been subdivided into three Sectorsas follows: a. Sector of the Pacific: Dr. John D. Long, Traveling Repre-sentative: Dr. Anthony Donovan, Traveling Representative; EdwardD. Hopkins, Sanitary Engineer. b. Sector of the Caribbean and theGulf: Dr. John R. Murdock, Traveling Representative; Walter Dashiell,Sanitary Engineer. c. Sector of the Atlantic: Dr. Felix R. Brunot,*Traveling Representative. Dr. Henry Hanson has remained as Travel-ing Representative at large, working mostly on a Pan American geog-raphy on malaria.

The countries visted by Dr. Long included: Argentina, Brazil, Chile,Colombia, Cuba, Dominican Republic, Ecuador, Haiti, Panama, Peru,Trinidad, Uruguay, and Venezuela. His travels during the fiscal yearrepresented a total distance of 38,133 miles; 32,730 miles by airplane,and 5,403 miles by other means of transportation. His time was mainlydevoted to discussing health questions with National Health Authorities,studying sanitary problems especially if of an international character,and furnishing such advice as was requested of him. Special attentionhas been given by him to antiplague work in Venezuela (June 27-July 4, 1941); Brazil (July 4-14-December 27-January); Peru (August-November-March-April-May-June, 1941); Argentina (December); Ecu-ador (August-November-February-May, 1941). Other problemsstudied were malaria in the Dominican Republic, Panama and Venezu-

*Died.

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ela; drafts of new health laws in Cuba, and water supplies in Chile,Ecuador, and Peru. Dr. Long also served on an advisory commissionappointed by the President of Perú to study improvement and ex-tension of the water supply of Lima and accompanied Dr. Murdockon a trip through the Caribbean zone (September-November 1940).

Dr. John R. Murdock remained during the year in charge of theCaribbean Sector, visiting the following countries: Colombia, CostaRica, Cuba, Dominican Republic, El Salvador, Guatemala, Haiti,Honduras, Mexico, Nicaragua, Panama, and Venezuela; some on twoor more occasions. The new Caribbean office is located at the GorgasMemorial Laboratory in Panama where routine work is done andspecial studies have been initiated. Sanitary Engineer Walter N.Dashiell is handling the engineering work for the new district. SinceSeptember 1940 cooperative work between this office and Venezuelahas been carried on. Studies were made of the Caracas water supply,house fly nuisance, garbage collection and disposal, and of dairies andpasteurization plants. Cooperative work has also been undertakenin the Dominican Republic. A preliminary study of malaria was madeand control measures were started at San Cristobal, Dominican Re-public. Dr. Murdock left the Caribbean district for a period of threeweeks during April to assist the Chilean authorities in the study andcontrol of an outbreak of poliomyelitis in. the province of Antofagasta.During the latter part of May and the first half of June, he made avisit to Costa Rica, Nicaragua, Honduras, El Salvador, Guatemala,Mexico, Cuba, Haiti, the Dominican Republic, and Venezuela to inter-view young doctors desiring internships in the university hospitals inthe United States of America.

The service of Traveling Representative F. R. Brunot commenced onAugust 1st, 1940. The month of September was spent in Panama,part of the time in the interior and the rest becoming familiar with thework as conducted by the Bureau Representatives in the field. InOctober, field and laboratory studies of plague as conducted in Peruwere observed, as well as the epidemiological features of this disease asmanifested in Peru. During November, this work was continued andin December a trip was made to Santiago as delegate to the Red CrossConference held in that city between the 3rd and 15th. Dr. Brunotcontinued this trip up to January 5th, in company with Dr. Long,visiting the cities of Buenos Aires, Rio de Janeiro, Montevideo, Recife,and Bahia, and meeting the men who are in charge of the public healthactivities in these districts and countries. In February he attendedthe meeting of the Directing Council of the International AmericanChild Welfare Institute in Montevideo, and during the same monthvisited plague ports on the Paraná in Argentina. In March some ofhis time was spent in Alpina in the state of Rio where a plague epidemic

15


was in progress, and visits were made to Santos and Sao Paulo to ob-serve the character of antiplague work there. In April he attended theConference of the Directors of Health of Brazil, meeting in Sao Paulo,and submitted reports on the water supplies and hospitals of Rio deJaneiro. During May he visited the northern part of Brazil and sub-mitted studies of the general health conditions. During this month,also he interviewed candidates from Brazil for medical scholarships andin June visited Buenos Aires, Montevideo, and Asunción with a similarpurpose.

Dr. Anthony Donovan spent most of his time during this year inPeru, acting as epidemiological adviser to the National Anti-PlagueService of Peru. A very promising new method of combating plaguehas been developed and tried out for the first time in Peru, namely,the fire torch or "flame thrower" to burn off excessive weed growthalong irrigation channels banks to expose rat burrows. A careful tryoutof the method was made during the year, first in Lima, and then in Villade Eten, Peru, where many plague-infected rats had been found priorto the initiation of the experiment, as well as a few human cases ofbubonic plague. Other possible uses for the flame throwers have beendiscussed in connection with insect-borne diseases, and especiallytyphus fever control, but so far no tests have been made. In July,1940, Dr. Donovan spent several days with Dr. Forrest E. Linder ofthe U. S. Census Bureau studying the present organization of the col-lection of vital statistics in Peru. During September and October of1940 he made a trip by land from Guayaquil, Ecuador toMacará,Ecuador, in the province of Loja, accompanied by the Director of theAnti-Plague Service of Ecuador, inspecting the field work of the Ecua-dorian Anti-Plague Service. In December, 1940, Dr. Donovan repre-sented the Pan American Sanitary Bureau at the inauguration of theWorkers' Hospital in Lima. During May and June, 1941, he went toBolivia and Chile to interview candidates for internships in UnitedStates hospitals. In June he returned to Bolivia and thence traveledoverland to Puno, Juliaca, Oroya, and other points in the PeruvianSierra to select suitable sites for an experiment in typhus vaccinationto be begun in August, 1941, by Drs. Dyer and Topping of the UnitedStates Public Health Service. During the year vaccinations againstyellow fever were performed on personnel of Pan American-GraceAirways Company, and other persons in Lima, using vaccine furnishedby the International Health Division of the Rockefeller Foundation.

Dr. Henry Hanson, Traveling Representative at large, while workingon a Pan American geography of malaria, traveled during the fiscalyear through Argentina, Bolivia, Chile, Ecuador, Panama, Paraguay,and Peru. He spent the first few days of July, 1940 in studying thecare of lepers in Paraguay. The rest of July and the first part of August

16


were spent in the Argentine studying especially malaria and plague con-ditions. The last two weeks of August were spent in Chile, visiting thedifferent branches of the Health Department, and in conferences with theNational Health Authorities. Dr. Hanson then went to Antofagasta andArica to study the possibilities of malaria in those areas. During themonth of September he visited Lima, Peru, and made local inspectionsof the Chillón valley as well as of the northern portion of the Peruviancoast, with a view toward the control of malaria. In October, he at-tended the Fifth Pan American Congress on Tuberculosis, held atBuenos Aires and Cordoba, Argentina, as representative of the PanAmerican Sanitary Bureau and of the National Tuberculosis Associationof the United States. On November, 1940, he visited Bolivia andattended the First National Conference on Malaria; and then went toLima to discuss problems concerned with malaria control. The monthof January was devoted to the study of the malaria problem in the highEcuadorean mountain regions near Quito. In Panama, Dr. Hansonstudied malaria conditions during the dry and rainy seasons, which aresomewhat parallel to the climatic conditions in the high altitudes and onthe coast of Peru, and in north central Argentina, and southern Bolivia.

Senior Sanitary Engineer Edward D. Hopkins traveled during thisyear through Peru, Ecuador, Bolivia, Chile, Argentina, and Paraguay.In the first part of the year he assisted with sanitation and public healthwork in and around Lima and Callao, Peru, after an earthquake whichoccurred on May 24, 1940. At the request of Prof. Laroza, Dean of theEngineering School of Peru, he prepared an outline for the SanitaryEngineering Course and presented it to the school. In order to facili-tate the work of the Anti-Plague Commission in Peru, maps of each ofthe departments of the country were prepared and blue printed. Anoutline was made and presented to the Commission of Doctors andEngineers of Peru, under the direction of Dr. Villalobos, with regardto the relation of malaria to the agriculture of the country, showing thebest methods for the study. In company with Dr. Akin of the U. S.Public Health Service, Mr. Hopkins made a study of the production,transportation, and pasteurization of the milk supply in Lima. Mr.Hopkins was the first to recommend flame throwers as a method tocontrol plague. By passing the flames over walls and floors (madeeither of wood or adobe) all insects are destroyed. During Septemberand October, 1940, a detailed study was made of the malaria and mos-quito problems in and near the city of Guayaquil, Ecuador. In com-pany with Sanitary Engineer F. E. De Martini of the United StatesPublic Service, Mr. Hopkins made a complete study of the Guayaquiland Quito public water supplies, and a report with recommendationsand costs was prepared. A complete survey and study were made ofthe water and sewerage needs of Asunción, Paraguay, and a written

17


report including recommendations and estimates was submitted to theExport-Import Bank. Assistance was given to the Sanitary Engineer-ing Bureau of the Department of Health of Chile, in the formulation ofrules to govern the use of raw sewage waters for irrigation purposes,and also for the protection of the sources of Santiago's drinking water.In Argentina, arrangements were made with Dr. Hackett of the Rocke-feller Foundation for the vaccination against yellow fever of all engineersand their families working in the interior of Paraguay. At the urgentrequest of the Minister of Public Health of Bolivia, a study was madeof the malaria and mosquito problems of the city of Cochabamba, and awritten report submitted. At the start of this school year, Mr. Hopkinscommenced teaching a class in Sanitary Engineering in the NationalEngineering School in Lima, Peru. A study of the sewerage system ofLima, Peru, was also begun.

Sanitary Engineer Walter N. Dashiell was assigned to the newlyestablished Caribbean Sanitary Zone on August 16, 1940, and dividedhis time between Panama, Venezuela, Dominican Republic, and Peru.His work in Panama consisted primarily in studies of the taxonomy ofthe Anopheline mosquitoes of the Caribbean area, anti-malarial meas-ures, water supplies, and sewer systems for the smaller communities,garbage collection and disposal, milk sanitation, and sanitation ofmarkets and abbatoirs. In Venezuela a study was made of the problemof garbage collection and disposal, and the control of domestic flybreeding in the vicinity of Caracas. Mr. Dashiell also investigated theCaracas milk supply. Reports with recommendations covering thesesubjects were submitted to the Health and Welfare Ministry. In theDominican Republic, Mr. Dashiell assisted Dr. Murdock in trainingthe personnel of a newly established Dominican malaria control unit.This was done by conducting a cooperative malaria survey in the com-munity of San Cristobal. Only two species of anopheline mosquitoes,A. albimanus and A. grabhamii were found in the vicinity, the formerbeing much more prevalent than the latter. In Peru Mr. Dashiellserved with a commission, the other two members of which were Dr.Long and Mr. J. A. Higgins, appointed to make a study of the publicwater supply system of Lima, Peru. The submitted report includedrecommendations relative to source, treatment, storage, and distribution,as well as physical, chemical, and bacteriological control of the Limawater supply.

Sanitary Engineer William Boaz spent the entire fiscal year in Mexico.The Texas-Mexico border was visited for a survey of pollution of theRio Grande waters and sanitation of border towns. The protectionof this stream against undue pollution has military as well as industrialimportance. With the cooperation of Mr. C. Cohen of the TexasDepartment of Health, and Engineer A. Lasage of the Mexican Health


Service, a program was formulated for the making of sanitary surveysand chemical and bacteriological tests of this river water. While inPiedras Negras, a Mexican border town, Mr. Boaz brought to theattention of the Douglas, Arizona, health authorities the necessity of atreatment plant to take care of the sewage from both Douglas andPiedras Negras. Likewise he recommended to the Phelps-DodgeCompany the building of a higher chimney for their plant or to providefor the washing or filtering of gases in order to avoid possible complaints.In the Federal District of Mexico a study was made of the pasteuriza-tion of milk, and the proper cleaning of premises where it was handled.Accompanied by Texan and Mexican health authorities, Mr. Boazvisited the oysterT producing areas of the Gulf in Texas and Mexico.Later trips were made to the oyster-producing areas of Tampico andVeracruz. Senior Sanitary Engineer E. Sullivan of the United StatesPublic Health Service, and Engineer A. Haneman, in charge of ShellfishSanitation for the Texas State Health Department, accompanied theexpedition with the Mexican authorities in effecting sanitation ofoyster production and handling. A new oyster code was drawn upwhich follows closely the best United States practices, and no doubtwill effect a great improvement in oyster sanitation. A study has beenmade of the mountain streams and lakes in Mexico with a view towardartificial propagation of rainbow and brook trout. The MexicanGovernment is also interested in developing an industry to producefish by-products, such as fish-meal, dried fish, fish oils, etc., and astudy is being made of this. A better distribution of the food-stuffsnow produced in Mexico has been recommended with a view toward awell balanced diet. The use of refrigerated trucks and quick freezingplants in the population centers would help, and a special study of suchfacilities has been made by Mr. Boaz. He also cooperated with theSanitary Engineering Department of the Mexican Health Service inthe working out of a program to provide the smaller towns with potablewater supplies. Visits were made to Puebla, Tlaxcala, Jalapa, Lerma,and Cuernavaca in connection with this program. Mr. Boaz cooperatedwith the Mexican Health Authorities in various emergency problems,like that of the earthquake of April 15th.; in drawing up a code forindustrial hygiene, and in the program for barber shop and beautyparlor sanitation.

INTERNATIONAL EPIDEMIOLOGY

Much, if not most, of the information presented here has been takenfrom reports especially requested from the national directors of health ofthe American Republics, supplemented by data contained in regularor special reports, as the case may be, received from national sourceseither by airmail or cable on the appearance of pestilential diseases or

19


of epidemic outbreaks of other communicable diseases. This is inaccordance with provisions of the Pan American Sanitary Code. Thelatest information thus received is incorporated in the "Weekly Report"of the Bureau which is regularly forwarded by airmail to all the healthorganizations of the American countries and to other interested in-stitutions elsewhere. When the situation justifies such a procedurethe radio or cable is employed to notify the countries more directlyconcerned. Weekly cable reports are likewise exchanged with theInternational Office of Public Health, as far as possible under existingconditions.

Cholera.-This disease has not made its appearance in the WesternHemisphere for a great number of years.

Plague.-As in former years, during 1940-1941 human plague con-tinued to prevail in the Republics of Argentina, Brazil, Ecuador, andPeru. Its presence was implied in another one, Bolivia, and wasreported for the first time in a number of years in a sixth, Chile. In aseventh, the United States, the disease appears to be entrenched, atleast in certain regions, in rodents or their parasites, and is movingslowly but progressively eastward, while human cases are uncommon.The other 14 American Republics had no evidence of human plagueduring 1940; in fact many of them have been free from the disease foryears. In order to combat this disease more effectively the followingcountries have organized and maintain national anti-plague services:Argentina, Bolivia, Brazil, Chile, Ecuador, Peru and Venezuela. Whileplague in America exhibits its usual fluctuations and no measurablecontinental progress against this condition can be reported, goodresults have been obtained in important maritime ports. Outstanding,for example has been the success in Guayaquil, Ecuador; Rio de Janeiro,Brazil; Iquique and Antofagasta, Chile; Callao, Peru; and Rosario,Argentina, to mention but a few. While scores of American ports wereformerly a menace to international navigation, human plague infectionat the time of this Report only exists in one important port and in 2or 3 minor ones (all Peruvian).

For purposes of simplification, C is used to express cases and D toexpress deaths in the following summaries:

During 1940 plague in Argentina showed a recrudescence whichassumed serious epidemic proportions, with a total of 228 C and 192 D,compared with 5 C and 4 D in 1939. This epidemic, accompaniedby an epizootic in rodents, especially in wild ones, constitutes the mostextensive plague outbreak in Argentina's recent history (last 10 years).It persisted through a rather long period, from April to the end of 1940,and affected a good number of provinces (Santiago del Estero, Cordoba,Salta, Tucuman, Jujuy, Catamarca and San Luis), but all ports re-mained free from the disease. No human plague has been reported forany Argentine port since 1936.

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No cases of plague were officially reported in Bolivia during the year1940, as compared with 21 C in 1939. This encouraging news will haveto be partly discounted, as the Bolivian health authorities recognizethe existence of the disease in an endemic form in the jungles, withoccasional outbreaks. Because the villages affected are usually verydistant and inaccessible to each other, the outbreaks do not spread far.

There was very little change in the Brazilian plague picture, with atotal of 97 C and 34 D reported in 1940, as compared with 81 C and 24 Din the year before. As usual, the highest incidence was recorded in thenortheastern region, especially the States of Pernambuco and Alagoas.The plague situation in ports is very satisfactory, no cases having beendiscovered in any of them since 1936. The national capital and mostimportant port (Rio de Janeiro) had its last human case in 1928.

Santiago, Chile, had 1 fatal case of plague in 1940, but this wasimported. No human plague has been detected in any of the principalChilean ports since the 7 C in Antofagasta and the single case in Iquiquein 1930.

The endemic situation in Ecuador has shown definite improvement inrecent years, with a decided drop in both morbidity and mortality,from 452 C, 244 D in 1939, to 69 C, 50 D in 1940, and probably lowerfigures in 1941. It will have to be admitted that the comparison appearsparticularly impressive because of the fact that 1939 was an unusuallyhigh year for Ecuadorian plague. On the other hand the trend in 1941points to figures decidedly lower than the average for recent years.Of the cases reported in 1940, 39 belonged to the Province of Chimborazoand 21 to the Province of Loja, both being areas identified with endemo-epidemic plague. No deaths were reported in the capital, Quito,during 1940 (2 D in 1939). Coastal plague continues presenting asatisfactory picture and the port of Guayaquil has had no cases sinceApril 14, 1939.

For the second year in succession an increase has been recorded inPeru: from 59 C 31 D in 1938 to 131 C 49 D in 1939 and 182 C 70 Din 1940. As in recent years, the Departments of Lima and Libertadwere at the top of the list, followed by Cajamarca, Tumbes, Lambayequeand Piura. One case was reported in the capital, Lima, but this wasascribed to a laboratory infection. Among the important ports, onlyPacasmayo reported cases (6 C 1 D). Also infected were the minorport-cities of Tumbes (15 C 3 D), Huacho (8 C 6 D) and Puerto Chicama(1 D), while Eten and Salaverry had rodent but no human plague. Ahopful note was sounded in the otherwise discouraging picture with thepassing of a resolution dated January 25, 1941, calling for the expansionof the National Anti-Plague Service, especially of the diagnostic andresearch laboratories and the field units.

For the second consecutive year a case of human plague was observedin the United States (June 10, 1940, in the State of Idaho; in 1939 one

2l

ANNUAL REPORT OF THE DlRECTOR

case was reported in Utah). The patient, a 13 year old boy, recovered.The locality is close to the eastern counties of Oregon which are knownto be infected with rodent plague. Investigation revealed that theboy had contact with rabbits and carnivorous birds shortly before theonset of illness. Infection was also found in wild rodents and theirparasites in the following 5 other western States (compared with 7the year before) as well as in the territory of Hawaii: California, Nevada,Oregon, Washington, and Wyoming. It was detected for the firsttime in Park County, Wyoming, A pool of fleas from a "cotton-tailrabbit" (Sylvilagus) was found infected in the State of Washington.This rabbit has also been found spontaneously infected in Brazil.

No further cases of human plague have been discovered in Venezuelasince the eradication, with the cooperation of the Pan American SanitaryBureau, of the 1939-40 epidemic (only 1 D in 1940) which accountedfor 11 C and 8 D in an isolated region of the State of Aragua. Plaguemay have assumed an enzootic form in that region (part of the Stateof Miranda included) since 1919, with sporadic outbreaks.

A thorough review of the history and epidemiology of plague in theAmericas is being published in the Boletín of the Pan American SanitaryBureau. It will be issued as a separate publication as soon as theseries is completed.

Dr. John D. Long, chief traveling representative of the Pan AmericanSanitary Bureau, states in his annual report for the fiscal year 1940-1941:"Antiplague work has been continued in Venezuela, Ecuador, Peru,Argentina and Brazil. There have been no cases in Venezuela for somemonths; only sporadic cases have occurred in the interandine region ofEcuador; during the fiscal year 67 C occurred in Peru, which is well belowthe annual average of 103 C; in the Argentine there has been an in-crease of cases due to the interference with grain exports and the re-sulting retention of large quantities of cereals; in Brazil there has beena slight increase in the number of cases as compared to the years imme-diately preceding the fiscal year.

"Studies and investigations made by the Pan American SanitaryBureau Epidemiologist Dr. Atilio Macchiavello in Brazil and in theinterandine region of Ecuador have clearly shown that plague is carriedover for long periods in the fleas, principally Xenopsylla cheopis, thatlive for long periods in rat burrows. This has made necessary certainchanges in antiplague measures, increased use of cyanogas and the useof flame throwers, for the purpose of destroying the fleas that infest therat nests and rat burrows and harbors. Other interesting and instruc-tive, as well as some new epidemiological observations were also made."

Typhus.-Only the Republics of Costa Rica, Dominican Republic,Honduras, Nicaragua, Paraguay, and Uruguay remained unquestion-ably in the non-infected class through 1940. A bird's eye view of the

22


typhus picture in America reveals certain improvements in variouscountries, but no sizable general progress. In fact, either the diseaseis now being identified in countries where heretofore it has existedunrecognized, or else some forms are actually spreading to new fields.

An outbreak of 3 C of typhus, none fatal, was reported in Argentinain the summer of 1939-40, in the Department of San Martin, Provinceof Santa Fe, which according to Professors Sordelli, Molinelli, and otherscorresponded to the rat-borne type. Recent medical literature hasalso referred to 3 C with a positive Weil-Felix in Jews who had residedin Argentina for several years (presumably of endemic typhus or Brill'sdisease). An earlier case, with a positive Weil-Felix, considered to beof the rat-borne type, was diagnosed in Adrogue, Province of BuenosAires, in 1937. An interesting case observed in the capital, Buenos Airesin Nov. 1940, was reported in the Anales de la Sala VIII, of the F. J.Mufiiz Hospital. It was concluded that the patient, a sorter of in-ternational mail, was probably infected by a louse adhering to a pouchof foreign mail.

During 1940, 1,097 C of typhus-1,040 in the Department of LaPaz-were reported by the national department of health of Boliviato the Pan American Sanitary Bureau as compared to only 599 C in1939, as listed in Demografía, annual report of the Bolivian statisticalservice. This represents a considerable increase, though it is attributedto a better control of the statistical services. The health authoritiesadmit that typhus, endemic in the Departments of La Paz, Potosi,Oruro and Cochabamba, constitutes a serious problem and that thenumber of deaths caused by this disease runs into the thousands, thecondition having existed probably since immemorial times in theBolivian plateau. The solution of the problem is complicated by theinsanitary conditions prevailing in most of the areas affected. Vac-cination on a large scale and systematic delousing are being enforced.Somewhat similar conditions exist in the case of relapsing fever, whichlately has been on the increase.

The number of typhus cases occurring in the territory of Brazil isnot known. A disease of the rickettsiasis group, clinically and epi-demiologically similar to Rocky Mountain spotted fever has been dis-covered in Itaborai, State of Rio de Janeiro. It appeared in epidemicform and accounted for 14 C. Five of the last 6 (and only) casessubmitted to laboratory confirmation, gave a positive Weil-Felix reac-tion. The rickettsial etiology was confirmed by blood inoculation inguinea pigs. Rocky Mountain spotted fever is known to occur in theStates of S. Paulo and Minas Gerais. This area constitutes one of the 3known foci in the Western Hemisphere (formerly 2, before the recentinclusion of Colombia). In 1940, 22 D were reported in the munici-pality of S. Paulo; 21 in 1939.

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In Chile, where typhus is likewise endemic and where it occasionallyflares into epidemics, the situation took a decided turn for the better,with a total of 435 C and 71 D (Estadística Chilena lists 98 D for theyear 1940), in contrast with 1,440 C and 310 D in the year before. Theprovinces presenting the highest figures were Antofagasta, with 68 Cand a morbidity rate of 56 per 100,000 inhabitants; Atacama, 28 C(rate 36.2); Valdivia, 51 C (rate 28.6); and Valparaiso, 70 C (23.2).The capital city of Santiago had 42 C and 13 D. According to theweekly reports received from the department of health in Chile thefollowing port-cities were infected in 1940: Valparaiso, 55 C 5 D;Antofagasta, 40 C; Valdivia, 27 C; Talcahuano, 19 C 3 D; Tocopilla,7 C; Iquique, 4 C and Taltal, 2 C 1 D.

To the two known foci of spotted fever in the western hemisphere(United States-Canada and Brazil) Colombia must now be added(interior of the Republic). The first outbreak (1934-36) accountedfor 65 confirmed cases with 62 D (a case mortality of 95%). A morerecent outbreak (1940-41) has occurred northwest of the other focuson both banks of the Negro River and on the right bank of the Villetain the Province of Cundinamarca. Research workers have recentlyreported the presence of typhus in 6 different localities of the Depart-ment of Nariño-22 C with laboratory confirmation, from March 1940to April 1941-and they suspect that the true number of cases was evenhigher as not all contacts could be investigated.

The official weekly reports arriving from Cuba for the year 1940 list 7C of rickettsiasis, 5 of them in the Province of Pinar del Rio and 2 in theProvince of Habana (rat-borne type). Physicians have also suspectedthe disease in Oriente and Camaguey. Heretofore all human rickett-siasis in Cuba had been supposedly traced to infected immigrants, butit now appears that some of these cases are autochthonous.

The presence of endemic type typhus in Ecuador was confirmed late in1939, some 10 D being imputed to this disease, 2 of them in Quito:Official reports for 1940 include 56 C and 16 D, in the inter-AndeanProvince of Pichincha, and a total of 23 D for the whole country.The figures for the capital, Quito, seem to be 16 C 6 D. One deathincluded in Guayaquil's statistics probably corresponds to a caseinfected in the interior.

In San Salvador, capital of El Salvador, 2 fatal cases, presumablyBrill's disease, were reported in 1939 and 2 additional ones in 1940.In a Salvador medical journal the appearance of 2 C of typhus in thelocality of Santa Ana has recently been published. One observer(Castro) believes that since the first suspected cases seen in 1936 thethe disease has been gaining ground in El Salvador. He mentions 18 Capparently belonging to the classic typhus group. The disease appearsto be confined to the cities of San Salvador and Santa Ana.

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According to official reports, typhus in Guatemala during recent yearshas been on the upswing: 1938, 234 C and 40 D; 1939, 364 C and 80 D;1940, 1,495 C and 329 D. Guatemala City communicated 18 C and4 D in 1940, exactly twice as many as in 1939. Despite the fact thatduring 1940 typhus in Guatemala appeared in epidemic form, affectingparticularly the Department of Quiche, Baja Verapaz and Guatemala,no cases were recorded in any of the principal port-cities. The diseasehas probably existed in Guatemala since colonial, perhaps pre-colonialtimes, but because of its relatively low mortality it has not been lookedupon as one of the major health problems.

The typhus picture in Mexico has not changed a great deal lately, asthe following figures show: 1938, 935 D; 1939, 1,312 C, 1,016 D; 1940,1,377 C, 923 D, though it should be added that during 1940 the diseasedid not appear in any of the principal ports. Typhus is quite wide-spread in the Republic of Mexico. The States accounting for thehighest figures were: Guanajuato, with 248 C; Mexico, 243 C; FederalDistrict, 183 C; Oaxaca, 138 D; Puebla, 134 C, and Zacatecas, 119 C,exactly the same states as in 1939, but in different order. Ten otherStates had less than 25 C each, and 3 did not communicate any in 1940.The capital, Mexico City, had 148 C 45 D (48 D in 1939).

The Annual Report of the Health Department of the Panama CanalZone includes 2 C and 1 D of typhus in 1939 (1 C 1 D in Panama City;the other case outside the Canal Zone, Colon or Panama City, butimplying, of course, territory of the Republic). The Report for 1940lists 4 C in Panama City. This is not corroborated by a recent reportof the health authorities of the Republic of Panama.

The 1,258 C of typhus reported in Peru in 1940 offer a somewhatfavorable picture as compared to 1,656 in 1939. The disease waspresent in a great number of Departments, affecting chiefly, as in formeryears, those of Cuzco, Puno, and Ayacucho, though remaining absentfrom all important ports.

Puerto Rico had 1 C and 1 D in 1940.In the United States, typhus in 1940 reached its lowest figures since

1936. The total of 1,882 C and 101 D makes a favorable contrast tothe high figures of the year before (2,995 C and 146 D). The States ofGeorgia (584 C), Texas (410 C), Alabama (289 C), were, as in 1939,at the top of the list but the figures were much lower in all instances.About 14 States were completely free from the disease and 14 othershad less than 10 C each. A retrospective glance reveals that from 1922up to 1939 typhus was on the upswing in the southern States, where it isparticularly prevalent. The incidence rates are highest in small townsbut rural areas are also affected. Several of the largest port-citieswere infected as follows: New York, 33 C; New Orleans, 31 C; Mobile,29; Charleston, 23; Tampa, 14; Los Angeles, 9; Galveston, 2; Norfolk,2; Philadelphia, 1. Rocky Mountain spotted fever: 1939, 560 C, 94 D;1940, 457 C, 82 D.

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Though typhus was only recently confirmed as being present inVenezuela, 50 C and 2 D were ascribed to it in 1940; and 16 C in 1939.The highest figures were those for the State of Bolivar (21 C 1 D)followed by Carabobo (11 C 1 D) and the capital, Caracas, includingsuburban areas (11 C). All the maritime ports were free from thedisease but the fluvial port-city of Ciudad Bolivar had 5 C.

Smallpox.-A rapid look at the smallpox reports reveals that 10 ofthe 21 Republics were free from the disease in 1940. Of the other 11countries, one had only 1 case; another but a few; 5 others showedsignificant improvements, if not all outstanding; in one the situationremained more or less the same as in the year before; in 2 the change wasnot ascertainable; and only one had higher figures to report. Thetrend was unmistakably encouraging.

Argentina was one of the countries having a perfect score in 1940,with not a single case of smallpox; this followed the favorable year of1939 when only 19 C 1 D were reported. This record has followed anuninterrupted annual reduction since 1936.

Despite the fact that the number of cases officially reported for 1940(342 C) was more or less the same as for 1939 (348 C and 84 D, as listedin Demografia, 1939, Bolivian statistical publication) the health authori-ties of Bolivia claim that the situation has improved materially in citiesand larger centers. As in the year before, the Department of La Pazrecorded the highest morbidity, followed by Potosi.

Figures for the whole country of Brazil are not available. However,information for 1940 for certain port-cities reveals that Rio de Janeirohad 23 C (21 of alastrim) and 6 D, Belem 20 C (alastrim), Porto Alegre7 D, Vitoria 1 D and Fortaleza 1 D. In Porto Alegre, where smallpoxhas formerly prevailed, close to 100,000 vaccinations were performedfrom August 1938 to 1940. The situation there is therefóre bound toimprove.

The 1,992 C and 44 D reported by the health authorities of Colombia,for the year 1940 represent a decrease, compared with the figures re-ported in 1939 (2,787 C, 76 D). However, since the Anuario General deEstadística listed 313 D for 1939, it is quite probable that the correctfigures for 1940 may be increased when the final data are presented.Though the disease was prevalent in the majority of the Departments,Antioquia, Valle, Huila and Caldas had the highest figures. Reportsfor 11 months of 1940 (February missing) show 12 C in Bogota (1 Din 1939), the capital; 5 C and 1 D in the port-city of Tumaco and 1 Cin Buenaventura, Pacific coast city facing the Dagua River.

After many years with a perfect record, the Dominican Republicreported the presence of smallpox in 1940, though it was only 1 C.

The smallpox situation in Ecuador shows a very satisfactory improve-ment: 1939, 23 C and 10 D; 1940, 3 C and 1 D; first half of 1941, 0.

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The capital, Quito had 1 C in 1940 and 2 D in 1939. All importantports were free from the disease in 1940, though Guayaquil had 2 C in1939. (Another report gives 8 C for Guayaquil in 1939).

Notice of 1 fatal case of smallpox in 1939 had been received at thePan American Sanitary Bureau as occurring in the Department ofSanta Ana, El Salvador. However, a recent communication from thenational director of health lists no cases in that Republic in 1939 or 1940.

The improvement observed in Guatemala in 1939 (11 C 2 D) continuedthroughout the year 1940, when only 5 C and 1 D were confirmed, butthe figures are officially estimated by the health authorities at 43 C 8 Dfor 1940 and 105 C 11 D for 1939. Guatemala City had 3 confirmedcases in 1940 while 17 were estimated; in 1939, 2 and 6 respectively.All principal ports were free.

In Honduras 28 D had been attributed to this disease in 1939. Theseare not mentioned in a recent communication of the health department,which likewise fails to report any cases in Honduran territory in 1940.

The downward smallpox trend experienced in Mexico in the lastdecade has continued throughout 1940 when 1,545 C and 1,203 D werereported compared with 2,319 C and 2,205 D in 1939, 3,253 D in 1938,9,430 D in 1934 and 17,405 D in 1930. The Mexican accomplishmentdeserves due recognition. The State of Michoacan was at the top ofthe 1940 list with 875 C, distantly followed by San Luis Potosi (166 C)and Guanajuato (140 C). Only the State of Colima had no cases toreport but about 20 others had less than 25 each. Mexico City re-ported 17 C and 3 D in 1940 and 6 D in 1939. The disease did notmake its appearance in any important port.

A recent report of the department of health of Nicaragua includes43 C 15 D of smallpox in 1940. The Pan American Sanitary Bureauhas no information on the situation in 1939, but this does not necessarilyexclude the possible presence of this disease.

Cases previously reported as smallpox in Paraguay for 1940, werelater found to be chickenpox. The area controlled by the nationaldepartment of health and the statistical service includes the capitalcity (Asuncion) and 24 other localities, with a total population of395,998 inhabitants.

Smallpox figures for Peru in 1940 (379 C) were higher than those for1939 (177 C). While it was present throughout the country, theDepartments of Junin, Huancavelica, and Puno, showed the highestincidence and mortality, and the principal ports apparently wereuntouched.

The United States smallpox figures for 1940 (2,795 C 15 D) represent adecrease of close to 70% from the 1939 figures, and even more from the1938 figures-one of the most significant accomplishments in theAmerican struggle against smallpox in recent years. In an area covering


12 States of the Atlantic coast and representing about 25% of the totalpopulation of the country not a single case of smallpox could be foundin 1940. In 18 other States there were no more than 25 C each, buton the other hand Minnesota had 416 C, Iowa 412, Colorado 243 andOklahoma 198. The case mortality was amazingly low. Apparentlythe only port infected was Portland, Oregon, where 1 C occurred.(Remarkable as the improvement has been in 1940 the authoritiesadmit that there is no justification for the presence of smallpox in theUnited States with the effective prophylactic means at hand.)

Recent smallpox outbreaks in Uruguay have been few and limitedin scope. Immunization was apparently neglected for a while, whichled to several local outbreaks late in 1936 and throughout 1937. Vac-cination was intensified, and in 1938 only 29 C were observed; in 1939the figure was reduced to 5 and in 1940 to 0.

The alastrim epidemic which began in Venezuela a few years ago hasbeen steadily reduced, though not completely eliminated, as the fol-lowing figures will indicate: 1938, 256 D; 1939, 3,839 C, 148 D; 1940,955 C, 20 D. Incidentally, these statistics do not bear out the allegedmildness of the disease in all cases. Because of the active vaccinationcampaign being carried out, the improvement is bound to continuethrough 1941. Most heavily infected in 1940 was the Federal District,with 176 C; followed by the States of Guarico, 117 C; Miranda, 73 C;Lara, 40 C. The city of Caracas, including suburban areas, had 174 C3 D. The main ports also recorded the infection: Maracaibo, 12 C;Puerto Cabello, 10 C; La Guaira, including surrounding area, 2 C;and the fluvial port of Ciudad Bolivar, 6 C. The statistical publicationAn. Estad. Epid. also lists 2 C in Coro.

Yellow fever.-Only two American Republics definitely reportedyellow fever (jungle type) during 1940 though a third one joined theinfected ranks during the first half of 1941, and a fourth admits itspresence in remote areas but can submit no epidemiological data.

The Republics of Argentina, Bolivia (in cooperation with the Rocke-feller Foundation), Brazil, Colombia, Panama, Paraguay, Peru, andVenezuela maintain yellow fever services including laboratories.

The national health authorities recognize the possibility of yellowfever having existed for years in an endemic form in the Bolivian jungles,with occasional flare-ups. Because the villages affected are very distantfrom each other the epidemics are not easily spread. For 1940 only1 C was officially communicated, in the Department of Beni.

Jungle yellow fever continued in Brazilian territory in 1940. In fact alarger number of deaths were confirmed-164-than in 1939 (126 D).As in the previous year, the State of Espirito Santo, with about 150 D,had the highest mortality. The States of Rio de Janeiro and MinasGerais reported a few cases. Four cases were recorded in the port-city of Vitoria.

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The reports of the Ministry of Labor, Public Health and SocialWelfare of Colombia gave a total of 21 D of yellow fever in 1940. Thisrepresents an increase over the year before (10 D). The departmentsaffected were: Tolima, Santander, Antioquia, Caldas, Cundinamarcaand Intendencia Meta. All ports were free. Yellow fever investiga-tions continue to be conducted in Colombia, and in 1939 a laboratorywas installed for the preparation of vaccine, etc. Between June 1937and April 30, 1940 about 175,000 persons were vaccinated in the areaaffected. The work of the Rockefeller Foundation in Colombia in1940 has thrown new light on the yellow fever situation, with thedemonstration of the presence of the virus in 2 species of mosquitoes:the sabethine and the haemagogus. It was also found out that while theyellow fever virus did not kill any of the 2000 wild animals that wereinoculated with it and "generally did not produce signs of illness, manyspecies had virus circulating in the blood stream while the animalswere running about, a condition that favored the spread of the virus."The following animals were found susceptible: among the Primates,man and monkey; Marsupials: the opossums, all species; Edentates:anteaters, sloths, armadillos; Rodents: agouti, paca, capybara, somespecies of mice. As a result of the investigations the RockefellerFoundation offers the following tentative generalizations: "1. Yellowfever is primarily a disease of jungle animals. The classical forminvolving transmission from man to man by the Aedes aegypti mosquitois more of a secondary cycle depending largely upon conditions ofpopulation concentration and mosquito breeding created by man him-self. 2. Transmission of jungle yellow fever appears to be by junglemosquitoes from animal to animal. 3. There is no animal reservoirof virus in the usual sense. Virus continues to circulate in the bloodof susceptible animals for three or four days only, and does not sub-sequently reappear. Mosquitoes, however, once infected tend toharbor the virus for the remainder of their lives, which may be severalmonths under favorable conditions."

According to the report of the Minister of Public Health to thePeruvian Congress, 2 fatal cases of yellow fever were confirmed byviscerotomy in 1940: the first case appeared in May in Pucallpa; thesecond case, in Saposoa, Department of San Martin, was reported inAugust. The necessity of preventive measures against the jungle typehas been fully realized by the health authorities. A resolution issuedon April 29, 1941, establishes free compulsory vaccination in the sus-ceptible regions as determined by the department of health. During thefirst half of 1941 several cases of yellow fever were reported in theDepartment of Junin.

No yellow fever having been officially reported in Venezuela for severalyears previous to the 1940-41 fiscal year, the Permanent Anti-YellowFever Service has been simplified with the abolition of the anti-larval

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stations at Ciudad Bolivar, Puerto Cabello and La Guaira, only theobsevation and viscerotomy units being maintained.

Poliomyelitis.-Keeping abreast of modern epidemiology and recog-nizing the progressive tendency of this disease, the Pan American Sani-tary Bureau has endeavored to prepare a sketchy but to a great extentrepresentative, picture of the poliomyelitis situation in America during1940.

Argentina: According to the Revista Estadistica Municipal, 3 D werereported as "acute poliomyelitis or polioencephalitis" in the city ofBuenos Aires in 1940; 5 D in 1939. In 1939, 2 C and 1 D had also beengiven for the Province of Entre Rios, and 5 C for the city of Rosario.A recent communication from the Argentine health authorities doesnot mention these cases.

Brazil: The serious poliomyelitis epidemic of Rio de Janeiro in 1939has been definitely checked and most of the principal port-cities alsorecorded a lower mortality during 1940: Rio de Janeiro, 21 C 8 D(1939, 230 C 23 D); Porto Alegre, 1 D (1939, 4 D); Salvador, 41 C 2 D(1939, 3 D). Other port-cities, such as Recife, which accounted for8 D in 1939; Vitoria, for 2 D; Natal, for 2 D, and Manaus, for 1 D,did not report any deaths in 1940. The municipality of S. Pauloreduced its mortality from 9 D in 1939 to 1 D in 1940. Altogetherabout 349 C and 42 D have been reported there from 1933 to 1939,but it is admitted that a good number of cases, probably abortive,passed unrecognized. The city has never had a real epidemic, thedisease having assumed there an endemic form with cyclical variations.

Chile reported 34 C and 4 D in 1940, compared with 24 C 5 D in 1939.The Prov. of Valparaiso had the most cases (8), but the highest ratewas Llanquihua's (4.1 per 100,000 inhabs.). The capital, Santiago,had 9 C and 3 D. Valparaiso with 2 C and Puerto Montt with 4 Cseemed to be the only important ports infected. In contrast with thefigures of the health authorities, Estadistica Chilena ascribes 20 D topoliomyelitis and acute polioencephalitis in 1940. Early in 1941an epidemic outbreak was reported in Antofagasta. Dr. Murdock,travelling representative of the Pan American Sanitary Bureau, whoinvestigated the poliomyelitis situation in Chile, called attention to themildness of the disease in the Pampa of Antofagasta raising the questionof whether the dry climate tends to influence the extent and type ofnerve involvement.

Poliomyelitis has appeared in Colombia for some time in an endemicform. Isolated cases have been seen in hospitals at Bogota, Medellin,Barranquilla and other cities, but there have been very few epidemics,among them, the largest and perhaps the only real epidemic, was theone of 1940, in the interior of the country, accounting for 138 C and 6 D,chiefly in the Department of Valle del Cauca. Both the case mor-

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tality and the paralytic sequelae were low. The only important portinfected was Buenaventura, on the Pacific Coast.

Costa Rica was free from poliomyelitis in 1940, after having 3 D in1939. The year 1941, however, brought a mild epidemic that startedin March and up to August had accounted for 24 C, 13 of them in thecapital, San Jose. The first outbreak of this disease in Costa Ricadates back to 1931, when 9 C were recorded; the second, to 1936 (17 C).

The final figures for poliomyelitis cases in Cuba in 1939 (67 C) wereactually higher than those published in the previous Annual Report.The number dropped to 29 C in 1940: 12 of them in the Prov. of Habana(4 in the city of Habana); 10 in the Prov. of Santa Clara; 4 in Oriente;2 in Pinar del Rio and 1 in Camaguey.

While 5 C were officially reported in the Dominican Republic in 1940,and 2 in 1939, a certain degree of doubt has been voiced by the Ministerof Public Health and Welfare, as to the diagnosis, who points out thatcases exhibiting meningeal signs are reported as poliomyelitis. Theonly case concurrently confirmed by several physicians was the onereported in 1941.

The poliomyelitis figures for 1940 in Ecuador have been placed bydivergent reports at 3 C 1 D and also 2 C; for 1939, at 3 C 3 D as wellas 2 D. Both report a fatal case in Quito.

No poliomyelitis was reported in Guatemala in 1940 as comparedto 4 C in 1939 in Zacapa.

Mexico had 21 C 14 D in 1940, and 25 C in 1939 (deaths were notincluded). Of the 1940 cases, 6 belonged to the Federal District and5 to the State of Sonora.

Nicaragua had 14 C in 1940.The director of health of the Republic of Panama has reported (1940)

2 C of poliomyelitis in the city of Panama, neither fatal. The AnnualReport of the Health Department of the Panama Canal lists anothercase for the city of Colon.

Cases of poliomyelitis reported in Paraguay for the year 1940 werenot confirmed later by the health authorities. It is not clear whetherthis denial also applies to 12 C reported in 1939, 3 of which were inAsuncion.

A communication recently received from the director of health ofPeru lists 62 C for 1940 and 14 C for 1939, with the Departments ofCajamarca, Tacna, Lima, and Puno showing the highest figures. Fivedeaths occurred in the city of Lima.

The Island of Puerto Rico had 9 C and 3 D in 1940 and 4 C in 1939.In 1940, 9,795 C and 1,026 D were reported in the United States,.

compared with 7,272 C in 1939. This figure is not only larger than theone for 1939 but also represents an increase of 33% over the average

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for the 5 year period of 1935-39 (7,343 C). Furthermore it is thehighest figure since 1935. Incidence of poliomyelitis seems to be higherin the north central States and much lower in the Pacific States. Thedisease was also reported in several of the most important port-cities:Philadelphia, 11 D; Los Angeles, 10 D; New Orleans, 6 D; San Fran-cisco, 3 D; Oakland, 2 D. New York City had 184 C and 17 D in 1939and 67 C 5 D in 1940; Baltimore 20 C and 5 C, respectively. By theend of the 1940-41 fiscal year another epidemic wave was on.

Uruguay: 3 C in 1940.There was a poliomyelitis epidemic in Venezuela from October 1940

to May 1941, responsible for 133 C and 18 D, according to preliminaryreports. For the calendar year of 1940, 65 C and 7 D were reported,compared with 9 C 2 D in 1939. The Federal District accounted for45 C and 4 D; the State of Zulia for 7 C, though it is officially admittedthat this figure is lower than the actual number. The capital, Caracas,and suburban area had 40 C 4 D. The important port-city of Maracaibohad at least 7 C, probably more; La Guaira, 5 C. (More recently arather large epidemic has been reported from Trinidad.)

Bartonellosis.-Though officially only 151 C and 59 D of bartonellosiswere reported in Colombia in 1940 (138 C and 46 D in the Departmentof Nariño, 13 C and 13 D in Cauca) the health authorities have estimatedthe total number of deaths caused by this disease, probably since 1936,at over 5,000. It has been most prevalent in certain areas in thesouthern part of the country some 50 miles from the coastline and ata height of 2,500 to 14,000 feet, and has drawn no race or sex line.Several cases of verruga peruana have been discovered in Ecuadorbut they do not constitute as yet a serious situation. However, sinceit has also been found present in neighboring countries, the Ecuadorianhealth authorities are on the alert. The presence of the disease inPeru and perhaps elsewhere, can be traced to the Inca era. To theold known verruga foci in the Departments of La Libertad, Ancashand Lima, others have been added in the same Departments and inPiura, Lambayeque, Cajamarca, Amazonas, Ayacucho and Huanuco.Though only an extensive scientific survey could determine the exactdistribution and epidemiology of this disease in Peru, prominent workershave pointed out that it would be easier to map verruga-free areas thanthose where verruga is present.

Chagas' disease.-To the growing list of American Republics whichhave reported the presence of Chagas' disease in man (Argentina,Brazil, Chile, Colombia, El Salvador, Mexico, Peru, Paraguay, Uruguay,and Venezuela), Costa Rica may now be added: two cases were recentlyidentified in Nicoya and confirmed in the laboratory. In Paraguaythe first autochthonous case of trypanosomiasis was identified either in1938 or 1939. In the United States the finding of infected insects and

32


mammals in the southwestern part of the country suggests the possibilityof human infection. At least 100 human cases have been recognized inVenezuela since its identification there for the first time in 1918. Up tothe beginning of 1940 the following States could be considered as in-fected: Guarico, Yaracuy, Aragua, Portuguesa, Trujillo, Zulia andMiranda. It is believed that a more systematic search would also re-veal the presence of the disease in other parts of the country.

OTHER EPIDEMIOLOGICAL DEVELOPMENTS

Brucellosis, which has been found to exist in many AmericanRepublics, among them Argentina, Brazil, Chile, Costa Rica, Cuba,Mexico (where it is rather widely distributed and apparently on theincrease), Panama, United States, Uruguay and Venezuela, has alsorecently been identified in El Salvador. The condition had beenrecognized there in 1940, but the infection could be traced to Palestine;however, another case reported in 1941 by the same physician, bac-teriologically and serologically confirmed, proved to be autochthonous.The patient was an 8 year old boy who had lived for two years in a farmnear San Pedro Masahuat. An outbreak of diphtheria in Argentinain 1940 which caused 1,223 D, demanded the attention of the healthservices. The possibility of an epidemic of encephalitis in Argentinahas been mentioned in medical literature, as an increased number ofcases were observed in Cordoba (36 C from March to June 1941) andin Buenos Aires (20 C). The disease has attacked primarily children,only 3 C being in adults. Some of these human cases coincided withan equine epidemic. In Cuba, according to the medical literature, theacute type characteristic of epidemic encephalitis is being supplantedby the chronic syndrome, very often parkinsonian. Though a reliablestatistical survey has not been made, it is believed that Cuba has neverexperienced the extensive epidemics of the temperate zones. Sporadiccases of encephalitis of unknown etiology have been observed for anumber of years in the United States, in the Valley of Yakima, State ofWashington, but in 1939, the number of cases reached for the first time,epidemic proportions, concomitant with the appearance of more than600 cases of equine encephalomyelitis. The condition reappeared in1940, when a total of 86 human cases and 20 equine cases were reported,with a lethality of 20-25%. In 1941 a real epidemic occurred, themost extensive ever experienced in the United States. Finally checkedin September 1941, it accounted for 1,080 C and 96 D in North Dakota;815 C in Minnesota; 250 C and 50 D in Nebraska; 180 C and 11 D inSouth Dakota, and 64 C and 6 D in Montana. (In Canada the Prov-inces of Manitoba-464 C 42 D-Saskatchewan and Alberta wereaffected.) The disease, which by laboratory findings was classified asof the occidental type of equine encephalitis, manifested the same

33


symptoms, though in somewhat mildér form, as that found in St.Louis and Yakima. It was not determined definitely'if mosquitoeswere involved in the large outbreak. The finding of the occidentalstrain of the equine encephalitis virus in a prairie chicken (Tympanuchuscupido americanus) infected in nature is of epidemiological interest,as this is the first evidence of the presence of the virus in a host otherthan man or horse during a human epidemic. Investigations conductedin Yakima Valley revealed the role of the Culex tarsalis as a vector.This mosquito is quite prevalent in the States west of the MississippiRiver. Mosquitoes had been found, at least in the laboratory, capableof transmitting the disease, but this is the first factual confirmationwith mosquitoes collected in the field. It is not known yet whetherthis mosquito is the only vector of the human type, or if other speciesare equally capable of transmitting the disease. New York City at-tributed 61 D to epidemic encephalitis in 1940. After investigating anew disease, denominated "peste loca", which appeared among horsesin Venezuela, in 1936 and reached a truly alarming condition by 1938,two research workers of the Ministry of Agriculture and Animal Hus-bandry isolated, for the first time in Venezuela, the etiologic agent ofinfectious equine encephalomyelitis, which differs from the otherencephalomyelitic viruses which have been described so far. Theinfluenza epidemic which invaded the whole island of Puerto Rico in1940 was already mentioned in the previous Annual Report. Final dataavailable place the cases at 79,870 and the deaths at 1,062. The peakwas reached in July: 65,783 C and 499 D. In November 1940 thisdisease also began to spread southward and eastward in epidemic formfrom the States of Arizona and California (United States), reaching itsacme in January 1941, whereupon it commenced to subside. As aresult of the intensive campaign conducted in northeastern Brazil bythe government of that Republic in collaboration with the RockefellerFoundation, the alarming spread of the Anopheles gambiae and thevirulent malaria which it produced havé been checked. No evidenceof this mosquito was found in Brazil during the last 47 days of 1940,even in areas formerly infected where the control measures had beenslowly discontinued. Though the campaign is not ended the probableoutcome may be justly viewed with optimism. Malaria was officiallyresponsible for 87,833 C and 10,546 D in Guatemala in 1940. Duringthe same year Paraguay also had an epidemic of malaria which spreadalmost throughout the whole country and accounted for 625 C and 6 Din the capital city of Asuncion alone. Measles appeared in epidemicform in the Republic of El Salvador, causing 1,214 recorded fatalitiesin 1939 and 1,751 in 1940. This condition also made its nation-wideappearance in Guatemala in 1939, when there were known 31,695 C,though by 1940 the figures had been reduced to 1,515 C and 303 D.

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Costa Rica's usually satisfactory epidemiological conditions were tem-porarily darkened in 1940 by an outbreak of whooping cough whichresulted in several thousand cases (3,016 C and 27 D reported). Anepidemic of whooping cough reported in Ecuador which accountedfor 6,977 D in 1939 and 7,134 D in 1940 converted this disease intothe principal cause of death of those two years.

BULLETIN

The circulation of the Bulletin has been maintained and even extended,although a constant effort is made to weed out names of people who arenot actually interested in public health. On June 30 there were 9,400subscribers in 4,300 towns.

Papers published in the Bulletin during the year 1940 have included,as usual, both original material and translations. The number oforiginal papers was 39, an average of over three in each issue. Thesubjects included in these papers have been: Anopheles darlingi;Bartonellosis; Beans in Nutrition; Cancer; Conference of NationalDirectors of Health; Chagas' Disease; Garbage Incinerators; HealthEducation; Hospitals in El Salvador; Industrial Hygiene; Leprosy;Maternal Welfare; Medicine and Stamps in the Americas; Nutrition;Pan American Health Day; Pan American Sanitary Bureau; Pioneersin Public Health; Plague; Pure Foods; Quackery; Roentgenphotography;Rural Housing; Sanitary Engineering; Scientific Institutions in LatinAmerica; Sewage and Industrial Wastes; Smallpox; Social SecurityHospitals; Syphilis; Syphilis and Pregnancy; Teaching of Hygiene;U. S. Pharmacopeia; Venereal Diseases; Vital Statistics in America;and Yellow Fever. There were featured also, as usual, the AnnualReports of the National Departments of Health of the various Re-publics.

Translated papers dealt with the following subjects: Anopheles;Avitaminoses; Chemical Warfare; Communicable Diseases; DentalClinics and Hygiene; Disease Surveys; Food Poisoning; Garbage Col-lection; Hospital Construction; Immunologic Methods in Pediatrics;Intestinal Parasitoses; Maternal Welfare; Nurses; Sex Education;Teaching of Medicine; Tuberculin Test; Tuberculosis Control; UndulantFever; Verminoses and Vitamins. Reviews of periodical literaturecovered the following topics: Bartonellosis; Blindness; Cancer; Diph-theria; Dysentery; Encephalitis; Flies; Goiter; Influenza; IntestinalParasites; Leishmaniasis; Leprosy; Malaria; Maternal and ChildWelfare; Measles; Meningitis; Milk; Mosquitoes; Mycoses; Narcotics;Nutrition; Pellagra; Plague; Pneumonia; Poliomyelitis; Rabies;Rheumatism; Scarlet Fever; Smallpox; Snake Bites; Spirochaetosis;Sprue; Trachoma; Trypanosomiasis; Tuberculosis; Typhus; TyphoidFever; Undulant Fever; Venereal Diseases; Water; Whooping Cough;Yellow Fever.

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Mention must also be made of the special number devoted to PanAmerican Health Day, which attracted much attention and demand.

Publication of material in English has been considerably extendedas the demand for the Bulletin in English-speaking countries has in-creased, and it is desired to make readers in those countries familiarwith developments in health conditions and medical research in therest of the hemisphere.

INQUIRIES (Consultas)

The quantity as well as the diversity of subjects about which theBureau has received inquiries from medical, social and governmentalagencies as well as from individual professional and laymen, is indicativeof the increasing value of this section of the Bulletin.

Of necessity the publication of inquiries is limited to those of specialimportance or of popular interest. Queries on the following subjectswere published during the past year (1941):

Acid-resisting bacillus; non-alcoholic beverages (North American regulations);American Hospital Association; American Medical Association; (organization);anemias (Shive's solution in diagnosis); aviation (physical examination forpilots); bacteria (thermolabile point); banana powder (chemical composition);bats (destruction); cancer (Pan American Union against; fight against congenitalcancer in America; American organizations); children's asylums (temporary);child welfare (bibliography); chlorophyll (in therapeutics); civil service (inpublic health); coli-aerogenous organisms; dead bodies (exhumation); dentalhygiene; diabetes mellitus (incidence in some Latin American countries and theUnited States); disinfection (terminal; premises and vessels); drainage of land(factor against disease); drugs (specifications for purchase); emetine (physiologi-cal action); food (eating meat of diseased animals); foot and mouth disease(transmission); footwear (use of by peasants); health education (history ofhealth units; posters; courses for inspectors; schools in the United States); health(Pan American Indices; in Mérida, Mexico; in Port of Spain, Trinidad); hemo-globinuric fever (treatment); hernias (treatment with injections); herpes (treat-ment of genital); hospitals (prevention of intra-hospital transmission of disease;in Costa Rica; prevention and research as well as treatment facilities); hyda-tidosis (diagnosis); housing (industrial; bibliography; mortality and morbidityin relation to); infants (Spanish bibliography on feeding; prevention and care ofdiabetes; population in the American Republics; apple diet in diarrhoea); Inter-national College of Surgeons; Intestinal schistosomiasis (reactions); Italchina;Ixbut (a galactogenous plant); leprosy (treatment with diphtheria toxoide);leukemia (roentgenotherapy); malaria (Eagle test; explanation of Wrights'staining method); malarial parasites (coloring); malarial zones (in Honduras,British Honduras, and El Salvador; rice cultivation); maternal protection (bibli-ography); medical assistance (governmental); medical directories (Latin Ameri-can), medical-statistical terminology; milk (labelling of dry, evaporated); mines(health and drainage); morbidity (statistics in U. S.; nomenclature); movies(health subjects); narcotics (U. S. laws); noise (ordinances in U. S.); NorthAmerican societies and 'magazines (microbiology, biology, and vitamines);onchocerciasis (in Mexico); orthopedic surgery (in U. S. Army); parasitology andtropical medicine (American centers); Parkinson's disease (treatment); pharma-


copeia (U. S.); physicians and hospitals (in European dependencies in America);poliomyelitis (prophylaxis and treatment); vitamins in prevention and treat-ment; sulfanilamide); pre-marital certificates; prisons (narcotics, alcoholism, andvenereal infections in U. S.); professional men (number in Latin America); prostig-min (in deafness); public welfare (institutions in U. S., budgets for public healthand welfare in the Carribean countries); quackery; quinine therapy during nurs-ing; disease reporting and medical vow of secrecy; Rorschach's test; rural health(bibliography); Schizophrenia (insulin therapy); school hygiene (bibliography);silicosis; snake poisoning (recent bibliography); social security (for cripples, inthe U. S.); social service and sanitaria; Sonne dysentery (diagnosis and treatment;morphology of the bacillus); spring water (sanitation of); stagnant water (oiling);stamps (public health and medicine); sterility (women); sulfadiazine; sulfanil-amide (in pregnancy); trachoma (sulfanilamide therapy); trichophyton tonsuransand rmalassezia furfur (bibliography); tropical medicine; tropics (medicine chest;prevention of disease); trypanosomiasis, American (treatment); tuberculosis(bibliography on serology; campaign against in the United States); typhoid(Vi antigen); venereal disease (legislation; basis for an anti-venereal campaignin the United States); vital statistics (importance of service); water (purificationwith ozone).

LIBRARY

The present fiscal year saw the addition of some 200 new journals andover 1,000 books and pamphlets to the Library of the Pan AmericanSanitary Bureau. It now receives more than 800 medical and publichealth journals, mostly from Latin America. The policy of bindingthe journals of national departments of health, bacteriological andresearch institutes, and compilations of public health laws, was con-tinued, and the Bureau was fortunate in being áble to complete someof its older collections. Surplus copies of publications, including somesent directly from Latin American institutions to the Bureau for thatpurpose, were distributed to outstanding medical and public healthlibraries. An encouraging development was the sending to the Bureauby a number of North American book publishers, of several copies ofmedical books for distribution to Latin American institutions.

While the Library's holdings, in constant use by the staff of theBureau, are available for loan on a limited basis only, about 200 journalsand books were loaned to more than a dozen institutions during thefiscal year. A number of workers have visited and used its collections,in such fields as public health, psychiatry, epidemiology and climatology,maternal and child welfare, syphilology, zoology and entomology, andhealth education. It is probable that in the future the facilities of thelibrary will be used even more extensively than at present following theappearance of the revised edition of the Union List of Serials edited bythe Library of Congress in which, for the first time, the holdings of thePan American Sanitary Bureau are given, since by making use of micro-film service individual articles may easily be made available.

Because of the constant requests for such material, the Library began

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during the fiscal year the reclassification of its steadily growing collec-tion of photographs of Latin American health institutions and activities.A number of such photographs were loaned for publication in otherjournals, as well as appearing in the BOLETfN and the policy of usingphotographic covers on reprints and publications of more generalinterest, was instituted.

Mention may also be made of the collection of Latin Americanmedical and public health stamps and seals which is being built up by theBureau. Numerous requests were received for the reprint of an il-lustrated article on this subject which was published in the BOLETfNon the occasion of the first Pan American Health Day, Decemnber 2,1940. It is of interest to note that special stamps connected withPan American Health Day have been issued by Costa Rica and Guate-mala, as well as a semi-postal stamp (Colombia) and a cancellation(Uruguay).

Other activities of the Library have been the preparation of surveyson certain subjects of general interest including nutrition, narcotics,.hay fever, health and living conditions, and scientific institutions inLatin America as well as briefer memoranda on other topics. Someof these have been published in the Boletin de la Oficina Sanitaria Pan-americana or issued separately. The Library has also loaned collectionsof Latin American health posters for scientific exhibitions, and distrib-uted among North American institutions a number of such posterssent by Latin American health departments for the purpose.

The list of Public Health journals from Latin America (Pub. 152),mentioned in the previous annual report, was widely distributed andmet with a very enthusiastic reception. An alphabetical list is nowbeing prepared. A revised list of scientific societies and institutions(Pub. 141) was also prepared during the year.

MICROFILM SERVICE

Toward the end of the fiscal year an agreement was worked out withthe Friends of thé Army Medical Library Association (which has aidedmaterially in developing the microfilm service of the Army MedicalLibrary) and the Coordinator's Office of Inter-American Affairs, whereby161 institutions, medical schools and medical libraries in Latin Americahave been chosen to receive for one year the weekly bibliographic publi-cation Current List of Medical Literature, together with microfilm copiesof articles which they may desire to consult. From July 29, 1941, whenthe project first began operation, to February 9, 1942, 236 orders formicrofilm (in many cases involving more than one scientific article)have been requested by 14 Latin American countries under this arrange-ment. In addition, 5 other Latin American countries as well as in-dividuals and institutions in the first group, have ordered microfilms

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on a payment basis. Some of the latter were already subscribers tothe service before the special project was undertaken. Through thecooperation of certain Latin American medical libraries, scientificarticles not available in the United States have been located in LatinAmerica and details concerning arrangements for securing photostaticcopies have been sent to the North American inquirers.

This service is already showing its usefulness. It is not only helpingto make American science better known throughout Latin America,but makes available scientific literature that otherwise would not proveaccessible. The microfilm service is undoubtedly one of the greatestadvances obtained in the graphic reproduction of man's thoughtssince the discovery of printing, and there is no question that its utilitywill continue to increase as its possibilities are better understood.

BIOLOGIC STANDARDS

The Pan American Sanitary Bureau has continued to use its goodoffices in the securing, through the National Institute of Health of theUnited States, biologic standards and strains of bacteria, for officiallaboratories and institutions in the other American Republics. It hasbeen the customary practice to send the material directly to the nationalhealth authorities when requests have been received from privateindividuals or establishments.

FINANCES

In the fiscal year 1939-40, expenses amounted to $102,971.51 andquotas received and other income to $79,831.99. The situation showeda marked imprbvement during 1940-41, expenses amounting to$92,083.34 and income, including quotas received, to $107,436.88.The financial picture is at present quite encouraging, and if a properwatch is maintained over expenses and these continue to be graduatedto income as in this fiscal year, the finances of the Bureau will remainon a stable basis. Funds not contributed by the supporting Govern-ments are, of course, not included in the above statement.

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PUBLICATIONS OF THE PAN AMERICAN SANITARY BUREAU

No. 1.-Prevenci6n de las Enfermedades Transmisibles. 60 páginas.No. 3.-Higiene Pre-natal. 7 páginas.No. 5.-Ordenanza Modelo para Leche. 11 páginas.No. 7.-Organización del Servicio de Sanidad Pública de los Estados Unidos. 26 páginas.No. 9.-La Profilaxis del Bocio Endémico. 10 páginas.No. 17.-Cornservación de la Vista. 6 páginas.No. 19.-Colecta, Examen e Identificación de las Pulgas Murinas. 11 páginas.No. 23.-Meningitis Cerebroespinal Epidémica (Meningocócica). 4 páginas.No. 25.-Amígdalas y Adenoides (Vegetaciones Adenoideas). 6 páginas.No. 26.-Tifoidea: Su Causa y Profilaxia. 4 páginas.No. 30.-Tratamiento del Paludismo. 4 páginas.No. 36.-Nomenclatura Internacional de las Causas de Muerte. 16 páginas.No. 37.-El Interrogatorio'en el Diagnóstico Precoz de la Tuberculosis Pulmonar. 3 páginas.No. 43.-Código Sanitario Panamericano. 23 páginas.No. 45.-La Declaración Obligatoria del Embarazo. 10 páginas.No. 46.-La Difteria en el Trópico. 15 paginas.No. 47.-Los Censos en Sanidad y en Epidemiología. 13 páginas.No. 48.-Higiene Comunal para el Pre-escolar. 5 páginas.No. 49.-El Diagnóstico de la Fiebre Amarilla. 14 páginas.No. 50.-Acta Final, II Conferencia Panamericana de Directores Nacionales de Sanidad. 16 páginas.No. 51.-Milk. 8 pages.No. 52.-Summary of Proceedings, II Pan American Conference of National Directors of Health. 14

pages.No. 53.-Vacunación Antidiftérica. 8 páginas.No. 55.-A Lucta Anti-Larvaria no Impaludismo. 6 páginas.No. 57.-Diagnóstico Retrospectivo de la Fiebre Amarilla. 6 páginas.No. 58.-ElI Problema de la Alimentación en el Uruguay. 9 páginas.No. 61.-Imrnunización Profiláctica de los Recién Nacidos con BCG. 22 páginas.No. 62.-Epidemiología de la Lepra. 5 páginas.No. 65.-La Higiene Mental. 11 páginas.No. 70.-Diagnóstico de la Tuberculosis. 6 páginas.No. 82.-Narcomanfa. 46 páginas.No. 88.-Antirratización de los Buques. 40 páginas.No. 90.-Control de las Enfermedades Transmisibles. 70 páginas.No. 97.-Acta Final, Novena Conferencia Sanitaria Panamericana. 20 páginas.No. 98.-El Problema de la Fiebre Amarilla en América. 10 páginas.No. 99.-Profilaxia de la Fiebre Amarilla. 6 páginas.No. 101.-Ninth Pan American Sanitary Conference. 8 pagesNo. 102.-El Saneamiento del Suelo. 17 páginas.No. 103.-Report of the Director of the Pan American Sanitary Bureau. 8 pages.No. 104.-Profilaxia y dominio del paludismo. 24 páginas.No. 105.-Fumigación de buques. 14 páginas.No. 106.-Snake-Bites. 10 pages.No. 108.-Las Repúblicas Americanas ante las Convenciones Internacionales de Sanidad 5 páginas.No. 109.-La Lucha Antivenérea. 27 páginas.No. 110.-Third Pan American Conference of National Directors of Health-Summary of Proceedings.

10 pages.No. 111.-Venenos Antirrata. 4 páginas.No. 112.-Tratamiento Anti-Leprotico. 14 páginas.No. 113.-Pautas de Organización Sanitaria. 12 páginas.No. 118.-Servico de Peste. 6 paginás.No. 121.-Actas de la Tercera Conferencia Panamericana de Directores Nacionales de Sanidad.

396 páginas.No. 125.-Pautas para Abastos de Agua. 16 páginas.No. 126.-Décima Conferencia Sanitaria Panamericana, Acta Final. 20 páginas.No. 127.-Lepra: Epidemiología-Clasificación-Tratamiento. 17 páginas.No. 128.-A ClassificaCao da Lepra. 5 páginas.No. 129.-Final Act: Tenth Pan American Sanitary Conference. 13 pages.No. 130.-Dixieme Conference Sanitaire Panaméricaine: Acte Final. 20 pages.No. 131.-X Conferéncia Sanitária Panamericana: Ata Final. 12 páginas.No. 132.-Modelos de Certificados de Defunción, de Nacimiento Viable, y de Defunción Fetal. 4 pá-

ginas.

No. 133.-Tenth Pan American Sanitary Conference. 14 pages.No. 134.-Los Preventorios en la Lepra. 8 páginas.No. 135.-Proyecto de Escalafón Sanitario. 12 páginas.No. 136.-Actas de la Décima Conferencia Sanitaria Panamericana. 941 páginas.No. 137.-Nomenclatura Internacional de las Causas de Muerte. 25 páginas.No. 138.-La Enfermería Sanitaria. 10 páginas.No. 139.-Mate. 8 pages.No. 140.-Alimentación. 22 páginas.No. 141.-Sociedades e Instituciones Cientificas de la América Latina (Scientific Societies and Institu-

tions in Latin America). 50 páginas.No. 142.-Demografía de las Repúblicas Americanas. 16 páginas.No. 143.-Educación Sexual Destinada a los Padres. 9 páginas.No. 144.-Estudio de Ciertas Cuestiones Relativas a las Vitaminas. 14 páginas.No. 145.-Lo que Debemos Saber sobre Cáncer. 6 páginas.No. 146.-A las Madres. 2 páginas.No. 147.-IV Conferencia Panamericana de Directores Nacionales de Sanidad: Acta Final. 9 páginas.No. 148.-The Pan American Sanitary Bureau and its Cooperative Work in the Improvement of Milk

Supplies. 4 pages.No. 149.-Half a Century of Medical and Public Health Progress. 20 pages.No. 150.-Medio Siglo de Adelanto en Medicina y Sanidad. 22 páginas.No. 151.-IV Pan American Conference of National Directors of Health (Final Act). 8 pages.No. 152.-Medical and Public Health Journals of Latin America (Revistas de Medicina y Sanidad

de la América Latina). 51 páginas.No. 153.-Annual Report of the Director of the Pan American Sanitary Bureau: 1939-1940. 34 pages.No. 154.-Reacción a la tuberculina. 6 páginas.No. 155.-Informe Anual del Director de la Oficina Sanitaria Panamericana: 1939-1940. 39 páginas.No. 156.-Pan American Public Health Quiz. 14 pages.No. 157.-Epitome del Segundo Suplemento (1939) de la Farmacopea E.U. XI. 20 páginas.No. 158.-Public Health and Medicine in Stamps of the Americas. 7 pages.No. 159.-Some Pan American Pioneers in Public Health. 5 pages.No. 160.-Scientific Institutions in Latin America: Part I. 47 pages.No. 161.-Indices Sanitarios Panamericanos. 3 páginas.No. 162.-IV Conferencia Panamericana de Directores Nacionales de Sanidad: Resumen de sus

labores. 29 páginas.No. 163.-Huertos escolares. 7 páginas.No. 164.-Clave diagnóstica para la clasificación en columna (tabulación) de las causas de morbidad.

18 páginas.No. 165.-Contribuciones al estudio de la peste bubónica en el nordeste del Brasil. 331 páginas.No. 166.-Health and Living Conditions in Latin America. 11 pages.No. 167.-The Work of the Pan American Sanitary Bureau in Relation to Child Welfare. 4 pages.No. 168.-La enseñianza médica en Estados Unidos. 22 paginas.No. 169.-El lanzallamas en la lucha antipestosa. 9 páginas.No. 170.-El entierro de la basura bajo un recubrimiento eficaz en Cristóbal, Zona del Canal. 11

páginas.No. 171.-Fourth Pan American Conference of National Directors of Health: Resumé. 26 pages.No. 172.-Pautas mínimas para el saneamiento de las minas del Perú en lo relativo a viviendas. 8

páginas.No. 173.-La fiebre amarilla en las Américas. 15 páginas.No. 174.-Diagnóstico y tratamiento de ciertas afecciones de los tropicos. 12 páginas.No. 175.-Housing and Hospital Projects of Latin American Social Security Systems. 15 pages.No. 176.-Annual Report of the Director of the Pan American Sanitary Bureau: 1940-1941 39 pages.

Adresser toutes les demandes a M. le Directeur de l'Office Sanitaire Panaméricain.Diríjanse todos los pedidos al Director de la Oficina Sanitaria Panamericana.Todos os pedidos devem ser enderecados ao Diretor da Reparticao Sanitaria Panamericana.Address all requests for publications to the Director of the Pan American Sanitary Bureau.

THE PAN AMERICAN SANITARY BUREAU is an independent internationalpublic healthorganization. It was created by the Second InternationalAmer-

ican Conference (1901-1902), organized by the First Pan American SanitaryConference (1902), and reorganized by the Sixth (1920). It is governed by aDirecting Council elected, together with the Director, at each Pan AmericanSanitary Conference, and supported by annual quotas contributed pro rata by allthe American Republics. The Bureau is interested primarily in the preventionof the international spread of communicable diseases, and also in the maintenanceand improvement of the health of the people of the 21 American Republics. Underthe provisions of the Pan American Sanitary Code (1924), it has become the centerof coordination and information in the field of public health, in the AmericanRepublics. It also acts as a consulting body at the request of national healthauthorities, carries on epidemiological and scientific studies, and publishes amonthly Bulletin, as well as other educational material. Pan American HealthDay is celebrated annually on December 2 in all American Republics. Addressall correspondence to the Director of the Pan American Sanitary Bureau, Wash-ington, D.C.

pan american sanitary bureau: annual report of the...

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