to the fact that no extensive box privy district was supplied with Potomac River water.

A strong argument against the supposed causative relation between box privies and typhoid fever exists in the fact that the very considerable reduction in the number of box privies that has taken place since May 19, 1896, has not been followed by a diminution in the prevalence of the disease named. The act which provides for the abolition of box privies wherever public sewers and water mains are available, was enacted on the date named, and was put into operation as soon thereafter as possible. Since that time and up to June 30, 1906, 4,530 box privies have been abolished by compulsory process, as shown in the following statement. Doubtless in some cases owners of property have anticipated compulsory process by voluntarily establishing sewer connections, but the health department has no definite knowledge of the extent to which this has been done.

Statement showing by fiscal years the number of box privies abolished under the provisions of the act of May 19, 1896.

It is impossible to say with any degree of accuracy just how many box privies were in existence when operations were begun under the act of May 19, 1896. In the report made on June 6, 1894, by a committee of the Medical Society of the District of Columbia, on the prevalence of typhoid fever within the District of Columbia, it is stated that the number of privies then in existence was 14,092, of which 8,959 were located within the limits of Washington and Georgetown, and the remainder, 5,133, in the "county." These figures were taken by the committee from the records of the health department, but I regard them as far in excess of the actual figures. On the other hand, a recent examination of the records of the contractor for the removal of night soil showed that 3,600 privies are now being cleaned by him. Since the citizen is entitled to the services of this contractor upon request and without cost, it is likely that his books show every privy within the more densely populated part of the District, where the householder can not dispose of the contents of his privy even if he desires to do so, and that they show a considerable part of the privies even in the more or less sparsely settled suburbs. Four thousand is probably very close to the number of privies now in existence.

If we accept the earlier figures, the number of privies in the District of Columbia has been reduced since 1894 somewhat more than 70 per cent. If we accept the later, without making allowance for privies constructed since 1896 for the service of new buildings, of the 8,530 privies that existed on May 19, 1896, 53 per cent have been abolished. And if we limit our inquiry to the urban district-that is, to that part of the District where sewers and water mains are available the percentage of decrease will be even larger, for all of the 4,530 privies abolished were within this territory.

If our box privies have been the principal foci of infection from which our typhoid fever has come, then typhoid fever should have ceased to exist about in proportion to the reduction in the number of such foci. But not only has there been no gradual reduction in the prevalence of typhoid fever accompanying the reduction in the number of box privies, but even the total reduction in the number of privies, amounting to not less than 53 per cent, has shown no effect whatsoever. Under the circumstances set forth above, it seemed to be impossible to charge our box privies with responsibility for the prevalence of typhoid fever in the District without doing violence to the facts or to the ordinary principles of reasoning.

Another suggested cause of the prevalence of typhoid fever in the District of Columbia is the consumption of shellfish. The following table shows the quantity of oysters and clams arriving in the District month by month during the year ended December 31, 1905, together with the number of cases of typhoid fever reported month by month during the same period. It hardly supports the hypothesis that seeks to connect the prevalence of the disease named with the consumption of oysters and clams. The statement as to the quantity of oysters and clams imported is made up from the daily reports of the inspector of marine products, which is based upon his observation and inquiry concerning arrivals of the articles named.

Statement showing the quantity of oysters and clams brought into the District of Columbia during the calendar year 1905, in relation to the number of cases of typhoid fever reported during the same period.

Inquiries made to determine whether patients suffering from typhoid fever had or had not eaten raw oysters shortly prior to the onset of their illness showed during 1905 that 3 had and 1,094 had not. In view of the extensive use of oysters and clams as articles of diet, as shown by the preceding table, and of the comparatively small number of cases occurring among those who had eaten recently such food raw, it would be hardly safe to say that they were the chief source of typhoid fever here, or even that they had caused it at all.

With a continually increasing knowledge of the facts and conditions of which an account has just been given, relative to imported cases, milk supply, water supply, box privies, and shellfish, the health department was continually being confirmed in the opinion that it, along with others more or less conversant with the situation, had accepted,

that the cause of nearly all of the typhoid fever contracted in the District of Columbia was the public water supply; and the Department looked forward to the day when the filtration plant would begin to operate as marking the beginning of an era when the prevalence of typhoid fever would be reduced by from 80 to 90 per cent, leaving only imported cases, or cases due to direct contact or to milk infection. When, therefore, the purification of the public water supply along lines closely approximating those that have proved successful in other places in reducing the prevalence of typhoid fever, failed to show any results whatsoever, the health department found itself without even a theory as to the cause of typhoid fever in this jurisdiction. And hampered as the department is for men and money, and devoid as it is even of a bacteriological laboratory, it was in no position properly to undertake the investigation necessary to establish the facts and conditions responsible for the existing situation. Under such circumstances the health officer recommended in June, 1906, that the SurgeonGeneral of the Public Health and Marine-Hospital Service be requested to investigate and report upon the situation.

The Surgeon-General of the Public Health and Marine-Hospital Service, acceding to the request of the Commissioners, appointed a committee to undertake the proposed investigation. This committee at the writing of this report is still engaged in its work. It is hoped that its report when submitted will point definitely to the cause of the prevalence of typhoid fever in the District of Columbia in such a manner as to permit direct and certain action to be taken for its eradication. Pending the publication of the results of that committee's report, the health officer will refrain from expressing any opinion or from making any recommendation.

Measles, whooping cough, etc.-The first real advance toward the restriction of the spread of measles, whooping cough, and other minor contagious diseases in the District of Columbia was made during the past year when the House of Representatives past a bill for that purpose a bill for the prevention of scarlet fever, diphtheria, measles, whooping cough, chicken pox, epidemic cerebro-spinal meningitis, and typhoid fever in the District of Columbia (H. R. 16868). It is sincerely to be hoped that this bill will become a law during the coming session of Congress. That a parent or guardian should be permitted to send a child into the public streets or into public conveyances or to the theater, church, other place of public assembly while the child is in a condition to disseminate, and in such a manner as to disseminate measles, whooping cough, or chicken pox is not creditable to the community in which such a condition exists. The theory that all children must sooner or later have such diseases, and that therefore there is no reason why a patient should not be permitted freely to expose other children to infection, is no longer accepted by intelligent physicians, and the sooner the community is taught the danger of such diseases the better. The average number of deaths each year during the past ten years from measles has been 23, and from whooping cough 66, and the expense and inconvenience that these two diseases have caused can not be estimated. Chicken pox, or what has been erroneously diagnosed as such, has been responsible for most of the outbreaks of smallpox that have occurred during recent years.

Tuberculosis. The opinion that has been gradually spreading throughout this country, and it might almost be said throughout the civilized

world, that the government must take definite action looking toward the limitation of tuberculosis, and that the first step in the movement is the reporting of cases of tuberculosis to a prescribed governmental agency, culminated in the introduction of a bill into Congress on March 6, 1906, for the prevention of tuberculosis in the District of Columbia. The discussion of this bill disclosed violent opposition on the part of a considerable number of physicians to the compulsory reporting of all cases of tuberculosis or of pulmonary tuberculosis, and substitute bills were submitted to the Commissioners by the Medical Society of the District of Columbia and by the Washington Homeopathic Medical Society. Pending a decision as to the merits of the several measures Congress adjourned, and the matter is still before the Commissioners and before the health officer, to whom the Commissioners have referred it for report. It is expected that a report will be made by the health officer at an early date.

The only substantial advances toward the prevention of the spread of tubercular diseases in this District that have been made during the past year was the issue by the Commissioners on May 3, 1906, on the recommendation of the health department, of an order intended to prevent the spread of such maladies in buildings under the control of the government of the District of Columbia and the appropriation by Congress of $100,000 for the erection of a hospital for indigent consumptives. The order, which is set out at length in the Appendix, is substantially the same as that promulgated a short time before by Fed eral authority with respect to buildings under control of the National Government.

DISINFECTING SERVICE.

For a statement of the work done by the disinfecting service during the past year, reference is made to the report of the inspector in charge of the contagious-disease service, printed in the Appendix.

ISOLATING WARDS.

For information as to the service rendered during the past year by the isolating wards for patients suffering from minor contagious diseases connected with Garfield Memorial and Providence hospitals, reference is made to the Appendix, report of the inspector in charge of the contagious-disease service.

RETURNS OF BIRTHS.

The total number of births reported during the calendar year 1905 was 6,415. This is the largest number ever recorded during a single year. There is no reason, however, for believing that the increase is due to an increase in the birth rate, and it is not believed that the registration is even now nearly enough complete to justify the computation and publication of such rates. The cause of the larger registration is the devising and adoption by the health department a few years ago of a plan for the better education of the public and the medical profession with respect to the necessity for recording births.

Since the beginning of the period named it has been the practice of the department, so far as the funds at its disposal for the payment of postage would permit, upon the filing by the attending physician or

midwife of a report of a birth, to send to the parents of the child an acknowledgment of the receipt of such report, so that they might be made aware of the existence of the law requiring such reports to be made and of the fact that the law had been complied with. As another means toward securing complete returns of births, whenever a death certificate is received showing the death of an infant under one year old, born in the District of Columbia, the record of births is searched to ascertain whether the birth of the deceased has been recorded. If no record is found one of the sanitary inspectors is instructed to call at the residence of the deceased and to learn the name of the physician or midwife who was in attendance at the birth of the child. To such physician or midwife a warning letter is sent, calling attention to the law on the subject, explaining that the department can not, without taking the bereaved parents into court as witnesses, prosecute in the case that has come to its notice, and therefore will not prosecute, but that in event of any further neglect on the part of the physician or midwife coming to the notice of the department, prosecutions will in any event be instituted. Prior to the adoption of the methods just described, the average number of births reported each year during the preceding decade was 4,750. During the two calendar years following their adoption the yearly reports have averaged 6,311.

Of children whose births were recorded during the calendar year 1905, 4,140 were white and 2,275 colored. The number of illegitimate births recorded was 657, or 10.2 per cent of all. Of the white children whose births were recorded, 94, or 2.3 per cent, were illegitimate, while of the colored children, 563, or 24.7 per cent, belonged to that class.

At the instance of the health department, a bill to provide for the better registration of births was introduced into Congress (S. 4506). The bill is similar to legislation heretofore advocated by the Department and introduced into our legislative body, but up to the present date nothing has been accomplished toward its passage. Its enactment would, it is believed, materially improve the registration of births in this jurisdiction, and is urgently recommended.

STILLBIRTHS..

During 1905 the total number of stillbirths recorded was 665. Of these 227 were white and 402 colored. The rest, 36, were of unknown race and represent fetuses, in the early months of conception, or in advanced stages of decomposition, or both, picked up about the streets and alleys and coming under the notice of the coroner. In so far as it could be ascertained by the attending physician, or by the coroner, whether the stillbirth was legitimate or illegitimate, of cases among white people, 10, or 4.7 per cent, were illegitimate, and among the colored, 116, or 33.7, had the same status.

RECORDS AND TRANSCRIPTS.

The following statement shows the number of transcripts issued from the records of the health department during the fiscal year ended June 30, 1906. As the fee fixed by law for the issue of such transcripts is 50 cents, the District has received $322 for such service.

D C 1906-VOL 3—3