New methods for the management of infants with kernicterus or erythroblastosis fetalis were proposed as a result of findings in another grant-supported project. Kernicterus occurs in newborn children as a result of Rh incompatibility. Of the estimated 2,000 patients yearly, approximately half die and half live with severe neurological disorders or mental deficiency. Previous treatment of kernicterus through blood transfusion rendered the disease latent, for either death or brain damage with the resulting cerebral palsy eventually ensued. A sensitive blood test was needed to determine the amount of bilirubin remaining in the blood after transfusion (thereby indicating the subclinical presence of the disease) and the level at which it constituted a danger. This means of measuring the amounts of bilirubin has now been obtained. With it has emerged the new practice of multiple exchange transfusions (recirculating the babies' blood several times) for all Rh incompatible infants within 48 hours after birth.

A grant recipient has elaborated a method which facilitates the difficult procedure of analyzing protein in spinal fluid analysis. Since the protein, gamma globulin, is elevated in patients with multiple sclerosis, this new methodology may provide a rapid, objective diagnostic procedure. Methods presently in use permit diagnosis only after the disease has run its course for an average of 6 years.

Bureau of Medical Services

The Bureau of Medical Services administers the programs of the Public Health Service which relate to care of the individual; the development of hospital, nursing, and dental resources; the construction of hospitals and medical facilities; and foreign quarantine. The Bureau operates the hospital and out-patient facilities of the Service and exercises professional supervision over personnel assigned to other Federal agencies for the administration of medical and hospital programs. Other functions include the development of data and the conduct of studies on nursing, dental, and hospital resources in the United States.

Hospitals and Medical Care

The Division of Hospitals conducts the medical care program for merchant seamen and other legal beneficiaries of the Public Health Service. Other beneficiary groups include the officers and enlisted men of the U. S. Coast Guard, officers and crew members of the Coast and Geodetic Survey, commissioned officers of the Public Health Service, Civil Service employees of the Federal Government injured

or taken ill as a result of their employment, and several smaller groups with specialized illnesses.

The Division also administers a service to Federal departments requesting consultation on establishing or improving health activities for their personnel. As one phase of this program, the Public Health Service operates 14 separate health units, most of them for agencies in the national capital area.

In 1954 the Public Health Service maintained 16 hospitals, 25 outpatient clinics, and 96 outpatient offices. Twelve hospitals provide general medical and surgical services; 1 is exclusively for patients with tuberculosis; 2 treat narcotic addiction and neuropsychiatric disorders; and 1 cares for persons with leprosy. Most of the hospitals are located at major ports. Outpatient clinics and offices are located in other areas where Service beneficiaries are concentrated. Staffed by full-time personnel, the clinics provide a range of medical, dental, and allied health services.

VOLUME OF SERVICES

Admissions to hospitals and clinics in 1954 reflected the curtailment begun in 1953 when one hospital was closed and five others were converted to outpatient clinics. The volume of services provided was also influenced by numerical reductions in some of the beneficiary groups-American seamen and Federal employees, for example-and by decreases in the numbers of patients referred by other agencies, especially the Veterans Administration.

Total inpatient admissions declined 16 percent-from 57,387 in 1953 to 48,282 in 1954; the average daily patient census dropped 11 percent from 6,335 to 5,640. However, outpatient visits fell only 6 percent, and remained over the 1,000,000 mark. The general hospitals admitted 43,329 patients in 1954 as compared with 51,545 in 1953. The daily number of patients at these stations averaged 2,947 or 12 percent fewer than the average for 1953.

SPECIAL HOSPITALS

The tuberculosis hospital at Manhattan Beach, Brooklyn, N. Y., maintained an average daily patient census of 343 throughout the year, a rate higher than its 325-bed capacity. The outpatient department registered 4,227 visits, a 12-percent increase, showing augmented interest of discharged patients in returning for checkups.

During the year, a laboratory to determine pulmonary function studies was established, and an outstanding chest surgeon served as consultant. These developments greatly increased the amount of successful chest surgery performed. An orientation program was

launched for patients and their visitors. Steps were taken to give hospital personnel a higher degree of protection against the disease.

The Public Health Service operates at Carville, La., the only hospital in the continental United States devoted entirely to the treatment of leprosy. Any patient with leprosy (Hansen's disease) in the United States may be admitted and will receive complete medical care and maintenance. The hospital also conducts diversified social service and community activities programs.

During 1954, the sulfone drugs still constituted the "treatment of choice" at Carville. Most sulfone-treated patients enjoy greatly improved general health, and if treatment is begun in the early stages, the ravages of leprosy can be avoided. Because the effect of these drugs is slow, clinical investigators at Carville are continuing the search for more efficient and quicker-acting agents.

Admissions to the Public Health Service Hospital at Carville totaled 60 in 1954, as compared with 90 the year before. The average daily census declined from 385 to 360, as patients with "closed" cases were discharged. As in many other chronic diseases, the patient with leprosy may enjoy long periods relatively free from disease activity.

The Public Health Service hospitals at Lexington, Ky., and Fort Worth, Tex., admitted 4,536 patients during the year, 13 percent fewer than in 1953. Treatment for narcotic drug addiction generally consists of withdrawal of drugs under close observation and treatment, followed by thorough medical, psychiatric, and social study. Through work therapy combined with psychotherapy, an effort is made to rehabilitate the patient so that he can meet the ordinary problems of living without recourse to narcotics. The medical staff advises a minimum of 135 days of treatment for voluntary patients. Those sentenced by Federal courts usually remain a year or more.

CLINICAL RESEARCH

Approximately 100 clinical studies were underway at Public Health Service hospitals during the year. Many of these were conducted as cooperative studies with other Public Health Service programs or as part of the individual hospitals program; others were initiated independently by staff physicians interested in a particular problem.

The Manhattan Beach hospital cooperated with the Division of Special Health Services, Bureau of State Services, in its chronic disease and tuberculosis program and tested the use of isoniazid in the treatment of tuberculosis. The Lexington hospital participated in cooperative research with the National Institute of Mental Health in a continuing effort to find nonaddicting, pain-relieving drugs as effective as those in the opium series.

PROFESSIONAL EDUCATION

In 1954, seven Service hospitals were approved for postgraduate preparation of physicians by the American Medical Association. The American Dental Association approved eight Service hospitals for dental internships. On July 1, 1954, 72 medical interns, 30 dental interns, and 111 residents were on duty. At several of the hospitals, qualified trainees participated in approved professional education programs in dietetics, pharmacy, physical therapy, occupational therapy, social service, medical record library science, anesthesiology, medical technology, X-ray technology, and hospital administration. The 1954 spring semester began an affiliation between the Public Health Service Hospital, Fort Worth, Tex., and Texas Christian University. Students received general orientation in modern hospital treatment of mental diseases. They then were given individual practice assignments, working with patients under staff instruction and supervision in such specialty areas as vocational guidance, recreation, occupational therapy, and educational therapy (which includes pastoral counseling by graduate students of the School of Religion). Official university credit is granted for work satisfactorily completed at the hospital.

FREEDMEN'S HOSPITAL

Freedmen's Hospital is the teaching hospital of the Howard University School of Medicine. It also operates a School of Nursing. The hospital has 329 general beds, 51 bassinets, and a 150-bed tuberculosis annex.

In 1954, Freedmen's Hospital admitted 11,746 inpatients, a slight increase over the previous year. The daily inpatient census in 1954, however, averaged 440 as compared with a 1953 figure of 457.

The outpatient department reported 56,061 visits to its 33 organized clinics. Registrations of new patients totaled 6,487. Each of these figures represents a slight increase over 1953.

Forty residents, 10 interns, 8 externs, and 4 fellows received advanced medical training. There were also 145 undergraduate medical trainees and 2 dental interns at the hospital. The School of Nursing enrolled 101 student nurses, 31 of whom completed the requirements for graduation. Other approved hospital training programs conducted at Freedmen's during the year included 2 pharmaceutical internships, 10 diabetic internships, and 1 administrative residency. Four social service students, one clinical psychology student, and 55 practical nursing affiliates also received experience and instruction in their fields.

During the year, approximately 70 clinical research projects were in progress, half of which reached completion.

The Women's Auxiliary of Freedmen's Hospital increased its membership by 35 percent-now numbering over 700—and organized a Junior Auxiliary of high-school students. The growth of this volunteer program offers continuing evidence of the cordial relationship between Freedmen's Hospital and the Washington community. Many local organizations contribute to the welfare, comfort, and entertainment of its patients.

Health Protection at Ports and Borders

To protect the Nation from epidemic disease imported from abroad, the Division of Foreign Quarantine enforces national and international quarantine regulations at all points of entry to the United States and performs the required medical examination of foreign citizens entering this country under the immigration laws and regulations.

During 1954, not one case of plague, cholera, yellow fever, smallpox, louse-borne typhus, or relapsing fever was reported in the United States. Total arrivals from foreign countries numbered 47,307 aircraft, 27,171 ships, and over 39 million persons.

Yellow fever was reported as far north as Honduras, Trinidad, and parts of Colombia and Venezuela. The vector of urban yellow fever, the Aedes aegypti mosquito, still exists in the South Atlantic and Gulf States in sufficient quantity to render many localities receptive should the infection ever be reintroduced.

Severe smallpox epidemics broke out in several parts of Asia during the year, notably in India and Indochina, and the disease remained widespread in Africa and parts of South America. Europe was comparatively free of smallpox, despite a mild outbreak in The Hague, Netherlands.

India had an unusually bad cholera year, but the infection did not spread beyond that general area. Less than a thousand cases of plague were reported in India-a mere 1 percent of the incidence 30 years ago.

MEDICAL EXAMINATIONS

Under the Refugee Relief Act of 1953, medical examination services were provided in Austria, Germany, Greece, Hong Kong, Italy, Japan, and the Netherlands. Of 8,000 refugees examined abroad, 165 were found to be excludable under immigration law, and 980 had other physical diseases or defects that may cause exclusion or require posting of bond. At United States ports, 127 refugees were examined; 1 was certified for excludable disease (tuberculosis) and 28 for diseases or defects that may cause exclusion.

Of aliens other than refugees, the number examined abroad by Public Health Service officers increased from 121,075 in 1953 to 147,539