social betterment activities, including especially lack of facilities for training midwives; and the want of a proper system for isolating the insane and preventing their propagation-these, in the judgment of the committee, are the principal causes for the extraordinary infant mortality.

These causes are discussed elsewhere in this report, excepting the question of the insane, which has received considerable discussion and study during the year, but has not reached a formulated program.

MIDWIVES.

The Legislature passed an act authorizing courses in midwifery in the Training School for Nurses, and the instruction will begin in April, 1915.

SPECIFIC DISEASES.

CHOLERA.

Cholera has occurred in the Philippine Islands in the years 1882, 1892, 1902, and every year since. In 1914 it appeared in July, almost simultaneously in Manila and the province of Rizal.

Upon the departure of Dr. Heiser shortly after the beginning of this outbreak on his long overdue vacation, Maj. E. L. Munson, Medical Corps, United States Army, was courteously permitted to advise the department and the bureau on the suppression of the disease. Investigation showed the existence of a large number of cholera carriers, and the bureau found it necessary to isolate these persons in San Lazaro hospital for periods of about 10 days each. In the early stages of this campaign some opposition occurred because these patients were apparently in perfect health, and they and their friends could not understand why their liberty should be interfered with. The bureau,,however, explained the necessities of the situation with the greatest patience to all persons interested, and by this means and through the cooperation of leading Filipino physicians (who gave it most readily and heartily), and also of the press, the opposition was removed, and the disease was soon effectively controlled, never reaching the proportions of 1911 or any of the preceding years.

LEPROSY AND THE CULION LEPER COLONY.

Dr. Paul C. Clements, as director, has continued his successful administration of the colony at Culion, assisted by Dr. José Martin, the assistant director, and upon his retirement by Dr. Vicente Frias. The Sisters of St. Paul de Chartres and Fathers Tarrago and Tomas have continued their devoted work.

As a result of investigations conducted by a committee of the Philippine Assembly and by the department in consultation with Commissioner Ilustre, Drs. de los Angeles and Santos of the Assembly committee on health, Dr. Velarde of the Colegio Medico Farmaceutico, Villa Real of the bureau of justice, and Mr. Miranda of the Assembly staff, several changes were made at the colony.

Compulsory labor on public works was abolished, but at the same time payments of money gratuities were discontinued to all the able

bodied men and a wage scale for all comers was substituted. This system has provided better and more regular labor at less cost and it has also had a tonic moral effect toward making the colony as nearly as possible a normal community.

The effort to encourage colonists to undertake normal occupations, especially agriculture, has been continued by the building of a road into the adjacent farming land, by legislative provisions for an agricultural supervisor, and for work animals and agricultural implements. The systematic planting of coconuts has been begun.

The nursing personnel was increased by the addition of two more Sisters of St. Paul de Chartres and the demand for more medical assistance was met by the establishment of a new medical position by the Legislature in the appropriation act. This position has been filled by the appointment of Dr. Oswald E. Denney, who, in addition to his clinical work, has undertaken a systematic research into the causes and transmission of leprosy.

Pending an increase of the appropriation the ration was improved without added expense by slightly reducing the quantity of meat on meat days and using the resultant saving to provide fish for additional days, so that either meat or fish was issued for every day in the week. The Legislature has now increased the appropriation for food from 200,000 to 240,000 so that still further improvements can be made.

While the methods of diagnosis preliminary to the transportation of patients to Culion were as secure as possible against error, it appeared that they were not sufficiently convincing to the patients and their friends, and an unfortunate impression existed that errors were occurring. This impression arose from the fact that cases adjudged to be positive upon the report of one physician would frequently show negative results on examinations by other physicians. The reason for this was that the leprosy germs are sparsely distributed in the system, so that any number of negative slides might result even from an unquestionably positive case; and so while any number of negative slides should be overruled by a single positive one. The general public, however, could not be expected to know this fact and therefore leper suspects and their families would be filled with false hopes upon receiving negative reports and with bitter doubts of the accuracy of positive reports.

To devise for the department a solution of these conditions a committee was appointed, consisting of Dr. Fernando Calderon, of the University of the Philippines, assistant dean of the College of Medicine and Surgery, and assistant chief of the Philippine General Hospital division of the bureau of health; Dr. I. Santos, of the Philippine Assembly; Dr. A. P. Goff, the chief of the San Lazaro Hospital division; Dr. E. Mercado, of the bureau of health; Dr. John A. Johnston, of the bureau of science; Dr. Luis Guerrero, representing the Colegio Medico Farmaceutico; and Mr. C. C. Batchelder, of the secretary's office.

This committee recommended the formation of a standing committee of three, consisting of one American, Dr. Johnston, of the bureau of science, and two Filipinos, Dr. Mercado, of the bureau of health, who had given much study to the subject of leprosy, and Dr. Ordoñez, of the Colegio Medico Farmaceutico, to pass finally upon all microscopic analyses, and especially to make their examination of all

slides at joint meetings, so that they should all pass upon the same slides and make a united report.

This recommendation was put into effect.

The same committee recommended the construction of two inexpensive buildings at San Lazaro Hospital for isolation of suspects, pending final diagnosis, so as to avoid danger of their being infected by the positive cases.

In order to give the colonists the satisfaction of seeing friends and relatives, and also to correct prevailing ideas about the conditions at the colony, the department arranged for a holiday visit of relatives and friends of the lepers from various parts of the islands. At the same time a delegation representing the Women's Club of Manila visited the colony, carrying a bountiful shipload of Christmas gifts. For the entertainment of these visitors the colonists provided an elaborate and successful program of festivities, including a concert, baseball and other athletic games, a competitive decoration of houses, a parade of decorated rafts, and an original play in Tagalog. These excursions appear to have worked a considerable change in the feeling not only of the colonists but of the families and friends from whom they are separated.

Following this celebration a library of some 7,000 volumes, collected largely by Commissioner and Señora de Veyra, has been sent there.

BERIBERI.

Beriberi caused 1,042 deaths during the year in Manila alone. It is one of the chief causes of the alarming excess of infant mortality throughout the islands. Further trial of tiqui tiqui has confirmed its value as a specific, but it is expensive, and the bureau of science was able to produce only enough for treatment of 700 infants. The permanent solution of the problem appears to lie in preventive measures. The experience of the year has strongly confirmed the opinion that the disease does not occur where unpolished rice, instead of polished, is used, and therefore I concur in the recommendation of my predecessor that the use of the polished variety be discouraged by taxation.

MALARIA.

Malaria was the subject of extensive investigations made during the year by the bureau of science and reported by Dr. M. A. Barber. The result indicates that the disease is transmitted only to small extent, if at all, by the A. rossi, and not extensively by the A. maculatus, but principally by the A. febrifer. As the A. febrifer breeds principally along the edge of rapidly flowing streams, where experience appears to show that it can be effectively eradicated at comparatively small cost, this discovery is likely to be of much practical value. The bureau distributed throughout the provinces 785,000 tablets of quinine of 5 grains each. While undoubted benefit has resulted from their distribution, no definite data have so far been obtained.

TYPHOID FEVER.

Typhoid fever is probably widely distributed over the islands, but no large outbreak or unusual condition has been reported. Every

effort is being made to suppress this disease by vaccination, improvement of water supply, and other sanitary measures, and also by a systematic educational campaign through lectures, pamphlets, and letters.

PLAGUE.

Plague, both rodent and human, has disappeared from the islands as a result of the vigorous antirat campaign, accompanied by the active enforcement of the ordinance in reference to rat-proof construction, and probably assisted to a great extent by the flood which occurred during September. The last case occurred on September 12, 1914. Measures will be continued with vigor, however, to prevent a return of the disease.

TYPHUS FEVER.

Typhus fever occurred only in a small outbreak in Mindanao, reported by Capt. George B. Foster, Medical Corps, United States Army. Eighteen cases, with one death, occurred. The disease was probably introduced by some Japanese laborers who came from Japan at a time when it was prevailing there very extensively. The outbreak was satisfactorily and rapidly handled.

CANCER.

Cancer has been generally supposed not to be as prevalent in the Philippines as in temperate countries. The opportunity afforded, however, in the Philippine General Hospital for the study of this disease rather indicates the contrary, but sufficient statistics have not as yet been obtained to justify a positive statement.

DIPHTHERIA.

Diphtheria occurred at intervals in the city of Manila throughout the year, but at no time was the number of cases sufficient to cause any particular uneasiness.

THE PHARMACY EXAMINATIONS.

In the early part of the year the irritation which had been growing for a long time in regard to the policy of the pharmacy board became urgent. Protests were lodged against the character of the examination prescribed by this board for pharmacy licenses, charg ing that the examination was of an arbitrary, catch-question type. better suited to prevent competent and well-trained pharmacists from entering the profession than to keep the unfit out.

Two large public hearings were held on this matter, after which the department appointed a committee which scrutinized the examination paper and advised the elimination of a number of questions as unsuitable. No other changes could legally be made, but the board was requested to mark the papers in a liberal spirit in order to pass those who were evidently qualified for efficient service. The board accepted these suggestions and a more successful examination

was held. Protests and appeals of disappointed candidates were referred to an independent committee, which sustained the board.

Subsequently, however, being unwilling to follow the opinion of the attorney general that they were bound by law to issue a license to a certain pharmacist who had practiced under the Spanish government, and being also unwilling to adapt future examinations to what appeared to be the just requirement of the islands, all three members resigned and successors were appointed.

THE PHILIPPINE GENERAL HOSPITAL.

REORGANIZATION.

After several public hearings and numerous conferences with persons interested some changes were made in the administrative organization of the hospital.

The former distribution of responsibility between the bureau of health, represented by a superintendent of the hospital responsible for certain phases of the work, the College of Medicine and Surgery, represented by a chief of staff responsible for certain other phases, and a School of Nursing, more or less independent of both, was replaced by a system in which all responsibility was centralized in one person, who is both chief of the Philippine General Hospital, division of the bureau of health, and dean of the College of Medicine and Surgery in the University.

Thus far the change has worked well.

PERSONNEL.

Under this plan Dr. W. E. Musgrave, dean of the College of Medicine and Surgery and chief of staff in the hospital, was appointed chief of the Philippine General Hospital, division of the bureau of health. He has succeeded in eliminating public dissatisfaction to a large extent and in stimulating a spirit of loyal cooperation among the officers and employees.

Prof. Fernando Calderon, vice dean and chief of the department of obstetrics in the College of Medicine and Surgery, has been appointed assistant director of the hospital.

PAY-PATIENT DEPARTMENT.

In order to avoid a feeling among private physicians that some of them might be discriminated against in caring for their private patients in the hospital, the pay-patient section was entirely separated from the other service of the hospital.

MEDICAL ATTENDANCE FOR GOVERNMENT EMPLOYEES.

This subject is discussed in connection with the act of the Legislature which dealt with it.

The service has been made more satisfactory by the special employment of two attending physicians (Dr. George B. Angle and Dr. Perpetuo Gutierrez), two attending surgeons (Dr. P. K. Gilman and Dr. José Eduque), and an obstetrician (Dr. Mariano Tolentino).