PAR. 64. Water-closets for each class of passengers, sufficient in size and number to meet their requirements, shall be supplied on all certified passengercarrying vessels; and in addition to those provided for third-class passengers there shall be a water-closet for the exclusive use of the crew, when, in the judgment of the insular collector of customs, this is necessary. Water-closets shall be well ventilated and shall be kept in a cleanly and sanitary condition by proper flushing after each time of using and by thorough washing down at least once daily. They shall be kept free from offensive odors by daily treatment with a 10 per cent solution of formalin or other approved disinfectant. It shall be the duty of the ship's officers to prevent the crew and steerage passengers from depositing excreta upon the decks or in the scuppers or in any place aboard other than the water-closets provided for herein; and said officers shall be held responsible if this or any other sanitary provision is not carried out properly.

PAR. 65. One or more bathrooms for each class of passengers shall be supplied on all passenger-carrying vessels making regular voyages of more than 36 hours' duration, and ships' officers shall be held responsible for the sanitary condition of bathrooms and surroundings.

PAR. 66. Cooks, stewards, and all other persons engaged in preparing or serv ing food shall be free from dangerous communicable diseases, and the sanitary inspector shall report all suspected violations of this regulation to the collector of customs, who will request the quarantine officer of the port to ascertain if the suspected person is so infected.

PAR. 67. No passenger or member of the crew shall be allowed to expectorate on the decks or in the scuppers of vessels, and ships' officers shall be held responsible for the enforcement of this prohibition.

PAR. 68. Masters shall make an inspection of their vessels each day when at sea for the purpose of maintaining a rigorous cleanliness in all portions thereof, and shall take such measures as may be necessary to destroy rats, mice, roaches, and other vermin.

PAR. 69. That class of light-draft vessels known as ferryboats plying on the waters of Manila Bay, Pasig River, and Laguna de Bay, and all other vessels having the status of ferryboats which navigate in Philippine waters shall be equipped as follows: Each such vessel shall be provided with a galvanizediron water can of ample size, having a faucet and a tight-fitting cover secured with a lock. Said water cans shall be placed high enough from the deck so that faucets may be easily reached. Nothing but boiled or distilled water shall be put into these cans. There shall be installed in a suitable place or room a sufficient number of pails of the dry-earth variety for the accommodation of the average number of passengers carried. Several extra clean pails shall always be carried for use in case of necessity. Under no conditions are these pai's to be emptied into the river; but upon return to Manila or to hailing port they shall be turned over to the city department of sanitation and transportation for disposal, and clean pails shall be received from that department to take their place. Galvanized-iron garbage cans of sufficient size, with tight-fitting covers, shall be installed and shall be placed at night on the river shore for emptying by the regular city scavengers. A kitchen sink for the purpose of washing dishes shall be installed, with a drainage pipe connected thereto. A urinal of the trough variety shall be installed for the use of male passengers, arranged so as to be kept constantly flushed by running water, the drainage pipe there. from to be led overboard.

(a) The foregoing provisions as to dry-earth and garbage pails shall not apply when the local United States Marine-Hospital Corps medical officer, or where

there is no such officer the chief medical officer of the government of the Philippine Islands, shall certify that the use of such dry-earth and garbage pails on ferryboats plying in his district is unnecessary.

PAR. 70. The Government sanitary inspector of vessels shall satisfy himself by personal inspection that the conditions required by these regulations have been complied with, and shall so certify to the collector of customs before clearance is granted.

PAR. 71. The failure of any vessel owner, agent, or master to comply with these regulations or the personal instructions of the sanitary inspector relating to sanitation and cleanliness shall be immediately reported to the collector of customs.

PAR. 72. At all ports of the Philippine Islands other than Manila the surveyors or other officers designated by the collector of customs shall be sanitary inspectors of vessels for the enforcement of the sanitary regulations herein provided.

PAR. 73. The sanitary provisions herein contained shall not be considered as abrogating quarantine rules and regulations now or hereafter in force.

PUBLIC HEALTH REPORTS

VOL. XXVIII.

DECEMBER 5, 1913.

HEAT AND INFANT MORTALITY.

By J. W. SCHERESCHEWSKY, Surgeon, United States Public Health Service.

No. 49.

Read before the Pediatric Section of the American Association for Study and Prevention of Infant Mortality, Washington, D. C., November 14, 1913.

By far the most conspicuous phenomenon in connection with the mortality of infants is the well-known increase in the number of their deaths which takes place in the summer months. No incidence of death in any other age group seems to be so immediately determined by meteorological conditions.

Hot summers produce an abnormally high infant death rate and cool summers the reverse. For instance, Kruse (30) points out that the infant death rate in German cities of over 15,000 inhabitants decreased from 190 in 1901 to 153 in 1910, a cool year. Yet, the universally hot summer (in Europe) of 1911 was accompanied with a great rise in the infant mortality, so that the infant death rate in these cities for that year was 187, a rate not surpassed by any year subsequent to 1901.

Again, Liefman and Lindemann (38) state that the total number of infants dying in Berlin in July and August, 1910, was 1,439, while in the same months of 1911, 2,050 died, an excess of 611.

The relation of heat to the summer deaths of infants has naturally been the subject of much statistical inquiry. Forty years ago, no doubt existed, in this country at least, as to the direct effect of heat in causing increased infant mortality in the summer. The discoveries and developments in bacteriology and the etiology of infectious diseases, however, gradually displaced heat into the background as a direct factor in the deaths of infants during the summer time. Until a few years ago the general opinion has prevailed that, while summer heat stood in casual relation to summer deaths, this relation was by no means immediate. Heat was regarded as an agent calling other deleterious influences into action.

Recent observations, however, particularly those in Germany, of Finkelstein (9), Rietschel (54, 55, 56, 57), Liefman and Lindemann (37), Klose (28), Kathe (25), and others have reopened the question. We must now ask ourselves if summer heat is not, after all, by its direct action the determinant of a large part of the summer mortality of infants.

It is to be regretted that the recent careful studies which have been undertaken abroad have not been duplicated to any great extent in this country and that it has been necessary to derive most of the material for this paper from foreign sources.

It has naturally been found impossible, within the limits of this article, to give complete treatment to the subject, but an endeavor has been made to summarize the more important observations.

Relations of the Summer Mortality of Infants to the Temperature Curve. In the past, numerous comparisons have been made and many charts published showing the relation of temperature to infant deaths. Owing to the great prevalence, in the summer, of deaths from intestinal diseases in babies, such curves have dealt mainly with the relation of temperature to deaths from this cause. Moreover, the mean temperatures for weekly or monthly periods have been the values taken with which to compare the infant deaths occurring in like periods.

The resulting curves are of a type familiar to us all. As an example, let us look at Chart I from Fuerst (54). This chart shows the monthly deaths of infants from gastrointestinal diseases in Munich from 1895 to 1904, as compared with the mean monthly temperatures.

It will be seen that the death curve lags behind the temperature curve, rising steeply to its apex in August and declining at a later period than the temperature curve, to reach the winter norm in December.

It has been pointed out by Miller (43) in this country, as far back as 1879, that we can not make reliable deductions from comparisons of this character. If we wish to study the direct effect, if any, of heat upon infant mortality, we must compare the daily deaths with the daily temperatures. More recently this was pointed out by Prausnitz (52), Finkelstein (9), Willim (63), Liefmann and Lindemann (37), Schwarz (69), and others. Willim and Finkelstein seem to have been the first to publish such curves, but the most careful study of this nature in recent literature is that of Liefmann and Lindemann, which deals with the relations of heat to infant mortality in Berlin for a period of 15 years.