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MEASURES FOR THE CONTROL OF THE INTERSTATE SPREAD OF POLIOMYELITIS AT PHILADELPHIA AND NEAR-BY CITIES.

Owing to the threatening situation arising from the prevalence of poliomyelitis at Philadelphia, Surg. M. H. Foster was directed under orders of August 29, 1916, to proceed to that city for special duty in the prevention of the interstate spread of the disease, and subsequently received orders to visit such other communities in the States of Pennsylvania, New Jersey, and contiguous territory as was required for a similar purpose. Dr. Foster was instructed to study the conditions then existing in Philadelphia and other cities and to recommend such measures as might be necessary and practicable to prevent the interstate spread of poliomyelitis, especially to the west and south, complaints having been received from various health officers that the disease was being introduced into their section from the centers referred to through the usual avenues of communication. In carrying into effect this order Dr. Foster was directed to confer with the health officer of Philadelphia and the health commissioner of the State of Pennsylvania and to endeavor to secure their cooperation in the establishment of a Federal system of notification, affecting children under 16 years of age departing from Philadelphia for points outside the State.

An office was established in the post-office building at Philadelphia and Dr. Foster proceeded on September 1 to Harrisburg, Pa., to confer with the State health commissioner regarding the situation. At this interview that official requested time to consider the proposed plan of certification and notification, which was similar in all respects to that in force in New York City, and also stated that he wished to consult with his advisory board regarding the matter.

On September 5 Passed Asst. Surgs. J. R. Hurley and Louis Schwartz and Asst. Surgs. M. S. Lombard and T. E. Hughes were directed to report to the medical officer in charge at Philadelphia for duty, and in addition seven scientific assistants and one stenographer were nominated and placed on duty.

On September 6 the health commissioner of Pennsylvania formally declined to cooperate in the plan proposed, but on the following day advanced a counter proposal for his office to exercise control over interstate travel by having State inspectors forward notification cards to communities in other States, provided the Government would arrange to frank such notices. This offer was approved, with the understanding that the State officers should temporarily accept positions as Federal officials in order to meet the requirements of the franking privilege and to satisfy the demands of health authorities that Federal action be enforced. The plan as outlined, however, was not accepted by the State commissioner of health.

In the meantime the force detailed to Philadelphia was employed in obtaining data concerning the epidemic and the local methods in force in handling the disease in different sections of New Jersey, Delaware, Maryland and Pennsylvania. Officers were detailed to investigate the situation and confer with the local and State authorities at Camden, Newark, and Trenton, N. J., Wilmington, Del., and Chester, Stewartstown, Logan, and Lansdowne, Pa. The State health officers of New Jersey, Delaware, and Mary

land were interviewed and expressed themselves as willing and anxious to cooperate in every way possible with the service in any measures which might be taken to prevent the interstate spread of the epidemic, and they submitted daily reports of all cases developing in their respective States, in many instances forwarding this information by telegraph. From this data incidence curves of the worse infected cities and towns were recorded and kept on file. Careful and complete studies were also made of the various transportation lines going out of Philadelphia and the number of children leaving the State from infected points ascertained by placing inspectors at the railroad and other terminals to estimate the number of outgoing passengers.

On September 9, Passed Asst. Surg. J. R. Hurley was relieved from duty at Philadelphia and directed to proceed to Baltimore for the purpose of conferring with the State health officer of Maryland relative to notification measures at that point, and on September 14 the seven scientific assistants were likewise transferred to Baltimore. Later, on September 15, the commissioner of health of Pennsylvania notified the service representative that he would cooperate in measures for the interstate control of the disease provided the measures instituted were made applicable to the entire State_of Pennsylvania and not limited to any particular section thereof. Inasmuch as this arrangement was considered impracticable, and would result in placing an entirely unnecessary burden upon travel, and as the number of new cases reported daily was rapidly diminishing, the offer was declined.

The epidemic in Philadelphia reached its maximum height the last week in August and began to slowly but steadily diminish from that time on. The same conditions prevailed in Camden, N. J., and in Wilmington, Del., although the number of cases was fewer. Newark, N. J., suffered severely, and a large number of persons contracted the disease, but the case rate decreased rapidly during the latter part of September. By October 1 it was evident that the epidemic, so far as these localities were concerned, was practically over and that no further safeguards were necessary.

MEASURES FOR THE CONTROL OF THE INTERSTATE SPREAD OF POLIOMYELITIS AT BALTIMORE, MD.

At the request of the secretary of the Maryland State Board of Health, concurred in by the health officer of the city of Baltimore, and in order to furnish State and local health officers with exact information regarding the travel of children from infected centers to uninfected districts, a notification and certification system, in all respects similar to that established at New York City, was adopted at Baltimore, Passed Asst. Surg. J. R. Hurley being detailed in charge of the operations in question under orders of September 13, 1916. On September 4 Asst. Surg. C. H. Waring was directed to report to the officer in charge for duty in this connection, and on September 22 Passed Asst. Surg. J. R. Ridlon received similar orders. In addition seven scientific assistants and three acting assistant surgeons were at various times assigned to the work.

Office space with suitable equipment was secured in the city health department building at 311 Courtland Street, this location being

such as to afford convenience to the public and ample facilities for the coordination of the work with that of the city health department. A circular letter was addressed to the general passenger agents of all transportation lines operating out of Baltimore, explaining the purpose of the system and requesting their cooperation in carrying it into effect. Officers were stationed at the main points of egress from the city and notification cards, based upon the issuance of a certificate by the city health office or the State board of health that the person did not come from premises where poliomyelitis prevailed, were forwarded to health officers at the point of destination, these cards being issued to children under the age of 16 years. While at no time was the poliomyelitis situation at Baltimore as threatening as that at New York or Philadelphia, the wisdom of the adoption of the notification system was unquestioned. During the 18 days the work was carried on the number of certificates issued amounted to 2,258, an average of 125 per day, practically all of these persons being bound for extra-State points. Upon the discontinuance of the work of notification at New York City, following the decline of the epidemic, orders were issued for the termination of the work at Baltimore, this being effected on October 4.

COOPERATION WITH THE MASSACHUSETTS STATE BOARD OF HEALTH IN INVESTIGATIONS OF POLIOMYELITIS.

Upon the request of the health commissioner of the State of Massachusetts service cooperation with the health organization of that State was undertaken in connection with the epidemic outbreak of poliomyelitis, and on September 22 Surg. L. D. Fricks was directed to confer with the commissioner of health and to render such assistance as was feasible. In conformity with this order and following the aforesaid conference Dr. Fricks was requested to proceed to Holyoke, where poliomyelitis was then epidemic, in order to relieve as far as possible the tense feeling which existed in the community and at the same time to assist the local health authorities in collecting epidemiological data bearing upon the influence of a comparatively rigid quarantine on the extent of the outbreak.

During the latter part of June and the early part of July there was an unusually heavy influx of families containing small children into Holyoke from New York City, the majority of these families leaving on account of the epidemic of poliomyelitis. On July 15 a case of infantile paralysis was discovered in a child recently arrived from New York City, and following the appearance of this case all families coming from suspected districts and all children from New York presenting service certificates were quarantined. No other cases were discovered until August 16, but between that time and October 1, 73 cases were reported, an incidence of slightly more than one per thousand.

The local health authorities made unusual efforts to secure the early diagnosis of poliomyelitis cases, two physicians being employed to study and report on all illness occurring among children. In this way early recognition of the disease was possible. All patients, with few exceptions, were immediately removed to a specially constructed hospital and the family from which the patient came was quarantined, together with other families using the same entrance in

apartments and tenements. Day and night watchmen were employed to guard all entrances and food supplies were furnished and delivered by the city during the period of quarantine. There can be no question that by the adoption of these methods direct personal contact between families in which the disease prevailed with others in the community was greatly restricted.

Considerable time was spent in assisting in the collection of epidemiological data and in so far as the cases observed were concerned the following conclusions were warranted: In the great majority of instances it was impossible to trace any direct contact with a previous frank case of the disease. While there were instances of more than one child in the same family being afflicted the rule was that those who became ill did so at or about the same time. Although several were under 1 year of age it was impossible to rule out all articles of diet other than mother's milk. No unusual presence of any biting insect was found and no single insect was discovered common to every infected house. None of the cases in Holyoke showed any very close connection with New York families, 66 in number, certified by the service and arriving in Holyoke subsequent to July 15 (it was fairly certain that these persons came from premises where poliomyelitis did not prevail), but there was an apparent connection between the homes visited by New York families earlier in the season and the points at which the earliest cases developed (many of these families doubtless came from homes where the disease was present). The amount expended by the city of Holyoke in attempting to control the epidemic and in the quarantine and treatment of cases was upward of $80,000. The part which was spent for sanitary surveys and the general improvement of conditions throughout the city was undoubtedly well expended. In conducting these surveys more than 100 unreported cases of measles and scarlet fever were discovered. By the construction of a special hospital for the treatment of infantile paralysis and the prompt diagnosis and early treatment of all cases, together with trained nursing, the patients received much better care than would ordinarily be accorded.

COOPERATION WITH MONTANA STATE BOARD OF HEALTH IN INVESTIGATIONS OF POLIOMYELITIS AT BILLINGS, MONT.

During the latter part of July, 1916, poliomyelitis appeared at Billings and other points in Montana, notably on the Crow Indian Reservation. Owing to the fact that certain local physicians were unable to agree on the diagnosis of these cases, many believing them to be cases of epidemic cerebro-spinal meningitis, the Montana State Board of Health requested that a service officer be detailed to investigate conditions. Accordingly, Surg. L. D. Fricks conducted an investigation during the early part of August, and subsequently Passed Asst. Surg. A. J. Lanza received instructions to institute a careful survey of the situation. It was ascertained that the epidemic, which while not extensive resulted in a high mortality, was unquestionably poliomyelitis, as bacteriological examination of the spinal fluid gave no evidence of meningitis, while a number of patients presented distinct paralyses, and that in all probability the disease had been spread by contact. Measures for suppressing the epidemic were recommended.

COOPERATION WITH THE STATE BOARD OF HEALTH OF MAINE IN INVESTIGATING POLIOMYELITIS AT ROCKLAND, ME.

Upon the request of the State Board of Health of Maine and the health authorities of the city of Rockland, Surg. D. E. Robinson on October 7, 1916, was ordered to proceed to Rockland, Me., for the purpose of investigating an outbreak of poliomyelitis and advising with the local authorities concerning measures for the control of the disease. The history of the epidemic, at the time the investigation was undertaken, showed that 37 cases had occurred in the city proper, with 9 deaths, and that 15 cases had developed in contiguous territory. While the local authorities had adopted energetic measures for the control of the infection, some question had arisen on the part of the public as to the necessity for the enforcement of such rigid restrictions. After carefully reviewing the situation and making a study of the cases which had developed definite recommendations were advanced concerning reasonable measures to be adopted for the control of the epidemic.

PLAGUE SUPPRESSIVE MEASURES IN NEW ORLEANS.

The period between June 30, 1916, and June 30, 1917, marked the third year in which plague suppressive measures were carried on in New Orleans. During this time service operations have been conducted as in previous years with but few minor changes. These changes have been characterized mainly by greater attention to specific rat-proofing problems, such as the delay occasioned by property owners on account of inadequate funds, conditions presenting engineering difficulties, careful inspection of new buildings, and cases in which owners resisted all efforts to make their properties rat proof. With the close of each fiscal year the problems of the succeeding year become correspondingly more difficult, owing largely to the fact that the places remaining nonrat-proof belong either to those who are financially unable to make the necessary alterations, or to those who will not willingly cooperate. During the past fiscal year, however, it is of interest to note the following: There has been an entire absence of human plague and an apparent suppression of the epizootic, as evidenced by the fact that during the past six months but three infected rodents have been reported and these at widely separated points, the last of which was confirmed on April 24, 1917.

A large number of very bad conditions have been remedied. The number of rodents examined at the laboratory has been considerably lessened.

Conditions along the water front are apparently improving.

The average number of fleas per rat on June 30, 1917, had markedly lessened as compared with the corresponding date of the preceding

year.

According to the board of health for the city of New Orleans and parish of Orleans, the general health of the community has improved, owing in part to the general cleaning up incident to rat proofing.

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