COLUMBIA UBHAfllES OFFSITE 
 
 HEALTH SCIENCES .STANDARD 
 
 HX00062553 
 
 H. L. Hoffman 
 
 A plea and a plan I'or the eradication of malaria 
 throughout the "e stern hemisphere. 
 
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 sl COLUMBIA UNIVERSITY 
 
 li HEALTH SCIENCES 
 
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'7?i//7-//'M^fy/c/i-Ai - 
 
 A PLEA AND A PLAN 
 
 FOR THE 
 
 ERADICATION o/MALARIA 
 
 THROUGHOUT THE 
 
 Western Hemisphere 
 
 By 
 FREDERICK L. HOFFMAN, LL.D. 
 
 Statistician 
 
 The Prudential Insurance Company 
 
 OF America 
 
 AN ADDRESS 
 
 Read in abstract before The SouUjcrn Medical Association 
 
 Tenth Annual Mwting 
 
 Atlanta, Georgia, November 14, 1916 
 
A Plea and a Plan 
 
 For the Eradication of Malaria 
 
 Throughout 
 
 The Western Hemisphere 
 
 By FREDERICK L. HOFFMAN, LL.l). 
 Statistician Tiik PiirntNTiAi. Insitranck Company ok America 
 
 Urad in ahstrart before 
 
 The Soiitlurni Mtilit-al AssiK-iation. Tfiifli Aiiniml Mci-tintf 
 
 Atlanta, (ieor^cia, NovcniluT I i. Ii»l«> 
 

 1917 
 
 PRUDENTIAL PRESS 
 
 NEWARK, NEW JERSEY 
 
 U. S. A. 
 
TO 
 
 THE NATIONAL COMMITTEE 
 (of the united states) 
 
 ON 
 
 MALARIA ERADICATION 
 
 Organized Mat 10, 191t; 
 In Accordance with Article 39 
 
 OF THE Final Act of the 
 
 Second Scientific Pan-American 
 
 Congress 
 
 Washington, 191G 
 
LIST OF SCIENTIFIC PUBLICATIONS 
 
 OF 
 THE PRUDENTIAI< INSURANCE COMPANY OF AMERICA 
 
 Available on Request 
 
 By John F. Dryden: 
 
 (i) The American Type of Isthmian Canal; 1906. 
 
 (2) Addresses and Papers on Life Insurance and Other Subjects; 1909. 
 
 (S) Uniform Laws and Legislation on Life Insurance; 1910. 
 
 (4) Industrial Insurance, Past and Present; 1912. 
 
 By Frederick L. Hoffman: 
 
 (5) History of The Prudential Insurance Company of America, 1900. 
 
 (6) Rural Health and Welfare; 191^. 
 
 (7) Exhibits of The Prudential Insurance Company of America, Inter 
 
 national Congress of Hygiene and Demography, 1912. 
 
 (8) The Significance of a Declining Death Rate; 1914. 
 
 I'J) The Chances of Death and the Ministry of Health; 1914. 
 
 (10) Practical Statistics of Public Health Nursing and Community Sicknes 
 
 Experience; 1914. 
 
 (11) Industrial Accidents in the United States and Their Relative Frequency 
 
 in Different Occupations; 1914. 
 {IS) The Mortality of the Western Hemisphere; 1915. 
 (IS) American Public Health Problems; 1915. 
 (IJt) The Documentary History of Insurance; 1915. 
 {15) The Mortality from Cancer Throughout the World; 1916. 
 {16) The Sanitary Progress and Vital Statistics of Hawaii; 1916. 
 {17) A Plea and a Plan for the Eradication of Malaria, 1917. 
 {18) Facts and Fallacies of Compulsory Health Insurance; 1917. 
 
 By Frederick S. Crum: 
 
 {la) A Statistical Study of Measles; 1913. 
 
 {2a) A Statistical Study of Whooping Cough; 1914. 
 
 {So,) Medical Inspection of Schools — a Factor in Disease-Control; 1915. 
 
 lia) Anthropometric Table; Children Aged Six to Forty-eight Months; 1916 
 
 {5a) The Mortality from Diseases of the Lungs in American Industry; 191( 
 
 CHARTS 
 
 / Mortality from Cancer (21 charts). 
 // Mortality from Tuberculosis (21 charts). 
 Ill Mortality from Measles (5 charts). 
 IV Mortality from Whooping Cough (4 charts). 
 
 V Mortality from Accidents (7 charts). 
 VI Mortality from Typhoid Fever (1 chart). 
 VII Mortality from Infantile Paralysis (1 chart). 
 VIII Mortality from Diphtheria (5 charts). 
 IX Mortality from Malaria (4 charts). 
 X Mortality of United States and Germany (3 charts). 
 
A Plea and a Plan 
 
 FOR THE Eradication of Malaria 
 
 Throughout 
 
 THE Western Hemisphere 
 
 PART I 
 A PLEA FOR ORGANIZED ACTION 
 
 PART II 
 
 A PLAN FOR ORGANIZED PREVENTION 
 AND CONTROL 
 
 PART III 
 
 SOME ESSENTIAL STATISTICAL 
 CONSIDERATIONS 
 
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PART I 
 
 A PLEA FOR ORGANIZED ACTION 
 
 3.V a resolution adopted by the Second Pan-American Scientific 
 ngress, the United States and all Pan-American countries obligated 
 •mselves, singly and collectively, to join in an effort to eradicate 
 larial diseases from the western hemisphere. However difficult and 
 larently impossible the task at the present time may seem to those 
 familiar with past achievements in disease prevention, there can be no 
 ^stion of serious doubt in the mind of those familiar with the facts 
 it the aim and end in view will be achieved in due course of time, 
 lether it will require one generation or ten to secure measurably 
 isfactory results will depend primarily upon the hearty and 
 cient cooperation of all governmental agencies, federal, state or 
 inicipal, and the international cooperation of all the principal countries 
 the western liemisphere, in which the disease is of relatively common 
 •urrence. Among the endemic diseases of our Southern States 
 laria ranks first in the order of practical importance, and the amount 
 suffering caused by it and the social and economic losses resulting 
 m it far exceed those of all the other endemic diseases, chiefly pellagra 
 1 hookworm, but also amoel)ic dysentery, leprosy and blackwater fever, 
 ving out of consideration for the time being whether the last named 
 »uld not properly be included within a broad definition of malarial 
 eases in general terms. Hookworm disease unquestionably is of 
 )rmous importance, but its eradication is less difficult than the com- 
 tc cliniiiialion of malarial disease, on account of the wider dissemi- 
 Lioii and the more insidious nature of malaria and the complicated 
 ationship between the mosquito and man. The fevers of the South 
 
 • a medical subject which has been under extended consideration from 
 
 • very setllerneiit of the coniitry, and, to a not inconsiderable extent, 
 iifhern medical practice and maliirial diseases, obviously or obscurely, 
 olve each other. 
 
 The literature of malaria is .so enormous that it hardly serves a 
 •ful purpo.se to refer even briefly to the earlier di.ssertations, such as 
 lie History, Diagnosis and Treat nu'iit of the Fevers of the United 
 ifes," by Klislia IJartlell, of wliicli the first edition was printed in 
 17, the less generally known "Observations upon the .\uluninal 
 vers of Savannah," by Dr. W. C. Daniel!, Savannah, IH-if), and the 
 .ssical treatise on "The Most Common Di.seiuses of the South," 
 Thonip.son McCiown. IMiiladelphia, IHIO, in which the congestive 
 CIS and the remittent fevers occupy the most prominent place. 
 
A PLEA FOR ORGANIZED ACTION 
 
 Fenner's "Southern Medical Reports" contain numerous and convincing 
 illustrations of the enormous losses caused to the Southern States 
 by the prevalence of uncontrolled malarial fevers during the period 
 immediately preceding the Civil War; and the medical history of that 
 great conflict* bears mute evidence to the havoc caused by malarial dis- 
 eases to the armies. North and South, because of the fact that the 
 underljang causes and conditions responsible for disease frequency were 
 completely misunderstood. 
 
 Contrasting these earlier inquiries and observations of the foremost 
 medical men of the period with modern works on malarial fevers by 
 Celli, with special reference to Italy, f by Ross, by Craig, by Thayer, by 
 Sternberg, by Henson, by Deaderick, and finally by the group of ex- 
 traordinary men in charge of the sanitary administration of the construc- 
 tion and maintenance of the Panama Canal, | the contrast is not more 
 striking, nor in a measure more indicative of a promising future, than 
 the earlier misconceptions of the cause of tuberculosis and the revolu- 
 tion in medical and sanitary practice following the immortal discovery 
 of the tubercle-bacillus, by Roljert Koch. In 1870, C. F. Oldham, M. D., 
 assistant surgeon of the Indian forces, and a fellow of the Royal Medical 
 and Chirurgical Society, wrote a monograph entitled "What is Malaria, 
 and Why Is It Most Intense in Hot Climates." His attempted ex- 
 planation left the problem unsolved. Forty years later the Royal 
 Society published the reports of a special malaria committee, in which, 
 in conformity to the exacting methods of modern science, the true fac- 
 tors and elements of the disease were set forth with admirable precision 
 and completeness, and continued the work with a series of eight reports, 
 ending with 1903. Step by step a new science of preventive medicine 
 has been developed, and of the ever-increasing group of preventable 
 diseases, malaria, without question, ranks first as the most obviously 
 eradicable of all. 
 
 The earlier speculations concerning the mode of infection have been 
 supplanted by exact scientific researches regarding the true mode of 
 transmission, confirmed by subsequent experience, and few now seriously 
 question the conclusiveness of the results. The mosquito as a transmit- 
 ting agent is to-day the recognized causative agent, although the mosquito 
 itself is not the cause, as is frequently assumed to be the case. The 
 parasite which develops malaria is transmitted by the mosquito toman, 
 and if the mosquito itself is not infected there is no possibility of malaria 
 causation. The mode of infection is thoroughly understood, and the 
 known facts about the mosquito have increased to the extent that the 
 subject has a literature of its own, and the methods of individual and 
 public malaria prevention are now common knowledge, however little 
 that knowledge may be publically applied. 
 
 ♦"Medical and Surgical History of the War of the Rebellion," Vols, i-iii, Washington, 1888. See, aLo, 
 article on Malaria, Index Surgeon-General's Library, Vol. x, Washington, 1905. 
 
 tSee, also, "Atlante di Demografia Medica d' Italia," by Dr. Enrico Raseri, Roma, 1906. 
 {Proceedings Canal Zone Medical Association, Vol. i-viii, Ancon, Canal Zone, 1908-1915. 
 
 8 
 
A PLEA FOR ORGAXIZED ACTIOS 
 
 As stated by Sir Ronald Ross, the most distinguished authority on 
 malaria, and himself the discoverer of the causative agent, or of the trans- 
 mission of the disease by mosquitoes, "malarial fever is perhaps the most 
 important of human diseases, and though it is not often directly fatal, its 
 wide prevalence in almost all warm climates produces in the aggregate 
 an enormous amount of sickness and mortality." In times past malaria 
 was not limited, and it is not even to-day limited, to warm climates, as 
 best illustrated in the "Essays on Fevers," by Miner and TuUy, pub- 
 lished at Middletown, Conn., in 1823, which includes an extended ac- 
 count of a yellow-fever epidemic in that community, however incredible 
 the possibility of such an occurrence may appear at the present time. 
 Remittent fevers in the Central States, in the prairie regions, along the 
 margins of the Great Lakes, in central New York and in New England, 
 during the early years when the country was being settled, caused a heavy 
 mortality, an enormous amount of sickness and a correspondingly con- 
 siderable economic loss.* By the settlement of the land, by the elimina- 
 tion of pools of standing water, by the drainage of swamps, gradually, 
 though at a truly lamentai)le cost, the northern section of the United 
 States has become i)ractically free from nudarial infection. There is still, 
 however, a measural>le remnant of malaria, and the possibilities of a 
 serious outbreak exist in every community where the anopheles mosqui- 
 toes prevail to a considerable extent. f The best illustration is the recent 
 epidemic in Greenwich, Conn., a very healthy suburban community near 
 New York, where, because of municipal negligence and private indiffer- 
 ence, the evil assumed such proportions as to call for drastic state and 
 even governmental interference. + In the great interior valley of Califor- 
 nia malaria prevails in many localities to such a degree as to prove a 
 serious hindrance in the development of otherwise promising localities, 
 
 ♦Sec Annual Ueporla of Ihc MiiliiRan State Board of Health. 1874. 1875. 1870, 1881, 188*. See, also. 
 "A Systematic Treatment on the Principal Diseases of the Interior Valley of North jAmerica," Vol. i, by 
 Daniel Drake, M. D., Cincinnati. 1850. 
 
 fAn exceedingly interrslinu reference to the occurrence of fevers during the pioneer period of Ihe Central 
 West appears in a report on tin- niedicnl lopoKrupliy and epidemic diseaso of Illinois, conlriliuted to the Trans- 
 actions of the American .Medical Association, Vol. xviii. Ptiiladelphiu, 181(7, reading, in part: "The te.«ti- 
 mony borne by the early explorers and settlers of the state of Illinois was anything but flattering to its character 
 for healthfulnes* and salubrity . . . Fevers due to miasmalic causes were "f frightful frequency among th« 
 pioneers, and, to no inconsiderable extent,. still prevail in the alluvial bottoms of the rivera." 
 
 In Ihc .same transactions was publi.shed a prize e.vsay on Ihe cause of interniitlent and remittent fevers, by 
 J. R. HIack, .M. I)., (if Newark, Ohio, in which references weur lo the freipieney of intermittent and remittent 
 fevers in the gold regions of California. The as.sumed law of inten.sily ami fre((uency occurrem-e in periodical 
 fevers is staled to be that: "With a summer mean lemperalure of sixty degrees, and upwards, the greater the 
 diurnal oscillations of tempi-ralure Ihe greater, caeleris parilius, will be Ihe prevah-nif of autumnal fevers, and 
 with Ihe increase of Ihe mean is the increased suseepliliilily lo fluctuations; Ihe higher the mean Ihe smaller, 
 comparatively, Ihe oscillation re<iuisile lo priMluce the morbid phenomena, and Ihe more intense their char- 
 acter" (p. 457). 
 
 }0f special value in this connect ion are Ihe following: A Report on the History of Inlermitlent Fever io the Ni« 
 Haven Region, contributed to Ihe Proceetlings of the (,'iinneclicul Molical Society, |H7<; An AcctiunI of 
 .Malaria in ( 'onneclicul. Including Observali ms i>n Malaria in (ireeiiwieh, as Karly as 1811, in the Fourth An- 
 nual Report of the Stole Hoard «.f lleallh of ( 'onneeliiul, Hartford, |H8<; An Account of Kpidemic Intermit, 
 lent Fevers in Connecticut, in the Fifth Annual Report of Ihe CiiiiMeclieul Stale Hoard of Health. Hartford, 
 IHH.i; A S|Mcial ReiH.rt of the llrnllh ( (fljcer of (Ire-nwich for IWK, in Ihe Thirtx -second ReiMirt of the Coo- 
 neclicut Slate Hoaril of Health. Hartford. lUl.i; Obsi-rvalions on MostpiiUi CondilDiis and .Muii^tiilo Surveys 
 in Connecticut in 1IM5, in Ih-- .\nnunl Rr|i<>rl of the Coiineclicul .Xgricultural FxperiiuenI Station, .New Havco, 
 1910; an exceedingly interesting e<iiiiiiiuiii<'ali<>ii from the (irr<-n«ick .Mixlical .S.K-iely was publubed in lb* 
 .New York ^/ub«, January Ml, lt)|3. 
 
 9 
 
A PLEA FOR ORGANIZED ACTION 
 
 and real-estate values are correspondingly depressed, because of the 
 natural aversion of people to live in, or to remove to, obviously un- 
 heal thful localities. 
 
 Sickness is no longer looked upon as inevitable or as an evil to be 
 borne without complaint. Ill-health is now recognized as a most serious 
 hindrance to the highest development of the individual and of the people 
 collectively considered. With an ever-increasing economic pressure the 
 necessity for the elimination of ill-health-producing conditions has be- 
 come a governmental problem of the first order of importance, and in no 
 special field of preventive medicine have the actual results of governmen- 
 tal interference and control been more satisfactory and conclusive than in 
 the prevention of malaria. Among the most useful summary accounts 
 of what has actually been achieved, attention may be directed to the 
 treatise on "The Health Progress and Administration in the West 
 Indies," by the late Sir Rupert Boyce, which includes some very 
 interesting observations on education as a prophylactic factor in the 
 West Indies, the war against insect pests, the law against stagnant 
 water in some of the West Indian colonies and finally the extension 
 of disease by modern commercial intercourse. More recent, and 
 still more instructive and conclusive, is the work on "Rural Sanitation 
 in the Tropics," by Malcolm Watson, being an account, amplified by per- 
 sonal observations, of what has been achieved in the prevention of malaria 
 in rural sections, chiefly of the Malay Archipelago, the Panama Canal 
 Zone, British Guiana, etc. Of special interest and value in this work are 
 the rules and regulations for estate sanitation, which are perhaps best 
 illustrated by the practical results obtained in the sanitary administra- 
 tion of Hawaii, chiefly with regard to the sugar plantations.* The 
 magnificent hospitals of the United States Rubber Company in the Dutch 
 East Indies have no parallel in any rural section of the southern 
 United States. Rural sanitation and malaria prevention in the South 
 are practically equivalent terms, and the one, broadly speaking, can 
 not be achieved without the other. Malaria prevention, to be perma- 
 nently successful, however, requires the most complete coordination of 
 governmental, corporate and private functions and efforts, to the same 
 extent to which this has been the case in Panama, where practically the 
 whole population has been brought under almost perfect sanitary control. 
 
 Thus far on the mainland of the United States we have not developed 
 a well-considered national plan for malaria eradication, nor have we 
 perfected even the underlying organization for an effective agitation of 
 the question as a matter of general public policy. Our schools of tropi- 
 cal medicine are poorly financed, and their work is far from having 
 attained to the practical importance of the corresponding efforts of the 
 Liverpool School of Tropical Medicine, which has sent out one malaria 
 expedition after another, as a result of which there has gradually been 
 brought together a series of monographic studies of actual achievements 
 
 *"The Sanitary Progress and Vital Statistics of Hawaii," Prudential Press, Newark, N. J., 1916. 
 
 10 
 
A PLEA FOR ORGAMZED ACT I OX 
 
 that may well challenge the admiration of mankind. Among others, the 
 school has reported on the malaria expedition to Sierra Ivcone, by Sir 
 Ronald Ross, the malaria expedition to Nigeria, by Annett, the progress 
 of the campaign against mosquitoes in Sierra Leone, by Taylor, the 
 prevalence of malaria in Ismailia and Suez, the malaria expedition to 
 Gambia, the sanitary conditions obtaining in Para, and finally a sugges- 
 tive outline of tlie practical study of malaria and other blood-parasite 
 diseases. AYith vast commercial interests to the south of us in countries 
 seriously hindered in their physical, social and economic progress on 
 account of the still extensive prevalence of malaria, we have practically 
 made no efforts in the direction of extensive scientific research deserving 
 of serious consideration, excepting, of course, the monumental work 
 carried on and completed under the direction of Major-General W. C. 
 Gorgas in Panama. 
 
 Regardless of our greater wealth and connnercial necessity we have 
 made no thoroughly scientific malaria research comparable to the results 
 rei)orted upon in memoirs by officers of the medical and sanitary depart- 
 ments of the Government of India, including monographs on malaria in 
 India, by Capt. S. P.James, malaria in the Punjab, by Maj.S. R. Christo- 
 phers, reports on the antimalarial operations at Mian Mir, !)y Capt.S. P. 
 James, and finally reports by the same distinguished authority on kala- 
 azar, malaria and malarial cachexia. It is true, of course, that malaria in 
 India is absolutely of the very first order of practical importance, and that 
 any measures and means of the Government of India in the direction of 
 malaria prevention are certain to prove productive of enormous value to 
 the i)eo|)le of India and the luiropeans who, jus civilians or for military pur- 
 poses, temporarily or ix-rmaiiently reside there. Hut the same conclusion 
 applies at least to the southern portion of the United States. .Vccordiiig 
 to Sir Ronald Ro.ss, it has been estimated that the mean animal death rate 
 of India from malaria is al)oul ;5 per 1. ()()(), and that the ammal actual 
 mortality is about 1,1S(),()()(). Fevers in India, as oflicially rei)orted, 
 unfortunately include diseases other than malaria, and the true 
 incidence of the di.sejise is, therefore, not at present iuscertainable, but 
 there is the most conclusive evidence that the seriousness of the problem 
 has been intelligently recogniz<Ml by the Govermnent and the people of 
 India, as illustrated in the series of transactions of the Coinmittee for the 
 Study of Malaria in India, edited by McKendrick and Christophers, 
 which include some exc<'editigly valuable notes and observations on 
 the .sea.sonable prevalence of ano|)helines, with special reference to the 
 potentialities of a single bn-rding-place. and the mat hcinatics and epi- 
 demiology of malaria, in amplilication of the ititcnvsting cliapler on the 
 measurement, mortality and cost of malaria in the treatise by Sir Ronald 
 Koss,* which involv<vs considerations also ap[)licable to other probjcnis 
 of prevental)le diseases. 
 
 •"The Pr.vrnli.Mi i.f Miiluria." Iiy il.Miul.l It..**. Nrw Y..rk. 11»I0. Atlentioii nwy »lii.> Ix- .lirrrlr.1 hrr« lu 
 the monuiiieiilul lrc«li»c on iiiitlarin by Dr. Vill.iri.. Awmli. publLiheti iiudor iho lille "l^ M»i«ri». " IViriuo, 
 Italy. 1015. 
 
 11 
 
.1 PLEA FOR ORGANIZED ACTION 
 
 Such scientific contributions as have been made to the subject of 
 paludism, through the transactions of the Committee for the Study of 
 Malaria in India, emphasize precisely the lesser degree of scientific 
 progress which, in this direction, has been made in the United States 
 regardless of the truly enormous social and economic interests involved 
 in malaria prevention, at least in the Southern States. We have much 
 to learn in this respect, and the results of scientific research in malaria 
 and related problems for the western hemisphere fall far short of the 
 corresponding attainments in the eastern hemisphere, as perhaps best 
 indicated by the remarkable results achieved by the Institute for Medi- 
 cal Research of the Federated Malay States, which in 1902 published a 
 monograph on "The Malarial Fevers of British Malaya," by Hamilton 
 Wright, subsequently enlarged upon by the recently issued treatise 
 on "Rural Sanitation in the Tropics," by Watson, previously referred 
 to, which has special reference to the antimalarial work in Klang, 
 Port Swettenham, and elsewhere in the Straits Settlements,* all more 
 or less in conformity to the control of malaria in Panama. The first and 
 fundamental principle of such an effort is a thoroughly aroused public 
 understanding of the importance and practical possibilities of malaria 
 eradication. Such conspicuous illustrations as the proceedings of 
 the Imperial Malkria Conference, held at Simla, India, 1909, the 
 proceedings of the Third General Malaria Committee, held at Madras, 
 India, 1912, the report on an investigation into the causes of malaria 
 in Bombay and the measures necessary for its control, by Bentley, pub- 
 lished in Bombay, 1911, and the two equally interesting and important 
 reports on malaria in Bengal, by Maj. A. B. Fry, published in Calcutta, 
 1912 and 1914, are sufiicientfor the present purpose of emphasizing the 
 measures and means which have been adopted in other countries than 
 ours, even though the question here, or at least in the Southern States, is 
 not less serious, when all the elements of the problem are taken into 
 account, than in the tropical portions of the British Empire. Regarding 
 no other problem in preventive medicine is the evidence so absolutely 
 convincing. Even tuberculosis can not show anywhere near the remark- 
 able results of actual reduction and gradual elimination which have 
 been the case with malaria whenever thoroughgoing methods and means 
 for complete eradication have been adopted. The statistical evidence 
 in support of this contention is so overwhelming that it may safely be 
 
 •In the Straits Settlements, according to the annual report of the Medical Department for 1915, by Dr. W. 
 Gilmore Ellis, the number of cases of malarial fever decreased from 9,474 in 1912 to 5,590 in 1915. The number 
 of deaths from malaria during the same period decreased from 660 to 311. The data are limited to the cases 
 and deaths in the hospitals of the colony. In the Federated Malay States, according to the annual report •>( 
 Dr. Chas. Lane Sansom, the mortality from malaria decreased from 17,870 in 1912 to 15,208 in 1915. The 
 report contains an interesting account of antimalarial measures in the different provinces and a report of the 
 Malaria Advisory Board under the supervision of an executive engineer. Appended to the report is a chart 
 showing the true malaria death rate for Kuala Lumpur Town for the period 1907-1915. During the first year 
 the malaria death rate was 9.7 per 1,000, which subsequently to 1911 was gradually reduced to 5.8 during 1912, 
 to 4.2 during 1913, to 3.9 during 1914 and to only 3.7 during 1915. This reduction, achieved through anti- 
 malarial measures, was obtained at an aggregate cost of $185,000, for the entire period, largely expended on 
 antimalaria drainage work. 
 
 12 
 
A PLEA FOR ORGAMZFJ) ACTIOS 
 
 asserted that it is primarily a question of general intelligence coordinated 
 to a high conception of public duty, without which the desired results 
 are not obtainable. 
 
 In Jamaica a malaria commission was appointed; it served for a few 
 years, rendered some admirable reports, achieved some far-reaching 
 practical results, but was permitted to terminate because of govern- 
 mental indifference and neglect.* The relatively small amount of 
 money involved in antimalarial measures in the island of Jamaica 
 could have been saved to advantage from almost any other item of public 
 revenue, with the practical certainty that no other expenditure would 
 prove productive of equally far-reaching social and economic results to 
 the population concerned. This most beautiful island of the West 
 Indies is a hundred years behind in the achievement of its most obvious 
 commercial and social possil)ilities, largely l)ecause of the extensive 
 prevalence of malaria, the impaired physique of the natives, the impossi- 
 bility of profitable cultivation of large infected areas, and the com- 
 plications resulting from malaria in the increased seriousness of many 
 other diseases. But in this respect many sections of our Southern 
 States have not done much better, and as yet not a single Southern state 
 has gone so far as to appoint a malaria commission or official state 
 committee for the purpose of making even a preliminary state survey for 
 the ascertainment of all the essential facts and conditions which require 
 to be known. 
 
 Over twenty years ago William Sydney Thayer and John Hewetson 
 pu})lished their momimental work on "The Malarial Fevers of Haiti- 
 more." That work itself constitutes one of the most useful and instruc- 
 tive sources of information regarding the malaria prol)lem. The report 
 was subsequently amplified by Dr. Thayer in a series of lectures on 
 malarial fevers (New York, 1897), including a concise outline of the 
 fundamental i)rincii)les of malaria pathology, diagnosis, prognosis 
 and trealmcnt. Some years earlier the late Dr. George M. Sternberg 
 published his work on "Malaria and Malarial Diseases," which, in 
 a more comprehensive manner, |)rescnte<l in broad outlines the con- 
 ditions governing the development and dissemination of malaria, with 
 observations on the spt'culalions and researches relating to the 
 nature of malaria and the general ellects of malaria, all of which 
 now make curious and interesting reading, since it was not until 185)8 
 that the tru<' cause of the disease was discovered by the ascertainment of 
 the malarial |)arasile in the mos(|uilo an<l the transmission of the disease 
 from mos(|uitoes to man. From Sternberg to Thayer, and from Thayer 
 to Craig and Deaderick, we have not been wanting in (jualilied medical 
 research fully on a par with the work of the most distinguished medical 
 authorities of other countries. Where we have failed, and ((Uispicuously 
 
 *Aniiiinl l{r|M>rt!i of lli<- Miiliiriji (°c)Miiiii'<iii>ii of Jiiiiiaiin, Drcriiilirr ;J1, lOIO. iitui for Ihr yrnr rnJiii( 
 Morrli.1l. lOU. KiiiK^ton, Jniiini<n, lOII-IUK. 
 
 Sor, niso. Ili«- AmiiiiiiI U.|iort of llir Sii|Mrinlrii(|i iil of nrnlllinf Jniiiiiira for tliryrnr rii.linK Mur.li 31. I»I3, 
 KinKslon, Janinii'n, 11)1*1. 
 
 l.i 
 
A PLEA FOR ORGANIZED ACTION 
 
 so, is in governmental recognition of the administrative aspects of 
 malaria prevention and control and the absolute hopelessness of any 
 measurable progress in the direction of eradication without more or less 
 drastic governmental interference. Within recent years some very 
 valuable local surveys have been made by the United States Public Health 
 Service,* and many scientific papers and reports have been contributed on 
 important technical aspects of malaria distribution, prevention and 
 control, but the efforts of the service in this direction have fallen short 
 of the required permanent results, in view of the want of the necessary co- 
 ordination of municipal, state and federal efforts, which, for their success, 
 require exact conformity to the admirable administrative principles de- 
 veloped under the direction of Major-General W. C. Gorgas and others in 
 Panama. The principles of mosquito control in the Panama Canal Zone 
 and the actual achievements in the local eradication of malaria and 
 yellow fever in Cuba and Panama have been set forth in an exceptionally 
 lucid and convincing manner by Joseph A. LePrince, formerly chief 
 sanitary inspector of the Isthmian Canal Commission, and Dr. A. J. 
 Orenstein, assistant chief sanitary inspector of the Isthmian Canal Com- 
 mission, in a work issued during 1916. f This is by far one of the most 
 notable contributions to the practical study of the problem of malaria 
 eradication, and every important factor of the problem receives adequate 
 consideration and is sustained by the gratifying results of actual ex- 
 perience. The essentials of an effective antimalarial campaign at 
 reasonable cost, largely on the principle of intelligent coordination of 
 governmental and other efforts and activities, more or less in conformity 
 to the methods found practical in the Panama Canal Zone, are briefly 
 set forth, as follows: 
 
 J. Meteorological and topographical conditions: these are, without 
 question, of the first order of importance. No definite conclusions can 
 be arrived at, however, without a preliminary analysis of the elementary 
 meteorological facts concerning a given community and the precise ascer- 
 tainment of the essential topographic features, by means of topographic, 
 
 *Among the more important of the recent publications of the United States Public Health Service on 
 malaria, malaria eradication, etc., are the following: No. 105, Antimalarial Measures for Farmhouses and 
 Plantations, by H. R. Carter, 191'2, No. 108, Malarial Fevers: Prevalence and Geographic Distribution in 
 Alabama, by R. H. von Ezdorf, 1913, No. 159, Malarial Index Work Methods Used in Obtaining Blood, Making 
 Blood Smears and Staining, by R. H. von Ezdorf, 1914, No. 160, Malarial Fevers: Prevalence and Geographic 
 Distribution in Arkansas, by R. H. von Ezdorf , 1914, No. 172, Malarial Fevers: Prevalence and Geographic 
 Distribution in South Carolina, Georgia, and Florida, by R. H. von Ezdorf, 1914, No. 175, Quinine Prophylaxis 
 for Malaria, by H. R. Carter, 1914, No. 186, Malarial Fevers: Prevalence and Geographic Distribution in Ala- 
 bama, 1913, by R. H. vou Ezdorf , 1914, No. 193, Malarial Fevers: Prevalence and Geographic Distribution in 
 Mississippi, 1913, by R. H. von Ezdorf, 1914, No. 217, Mosquitoes and Malaria: Report on a Short Trip in 
 Eastern North Carolina, by Chas. Wardell Stiles, 1914, No. 244, Impounded Water: Some General Considera- 
 tions of Its Effect on the Prevalence of Malaria, by H. R. Carter, 1915, No. 257, Impounded Waters: A Study 
 of Such Waters on the Coosa River in Shelby, Chilton, Talladega and Coosa Counties, Alabama, to Determine 
 the Extent to Which They Affect the Production of Anophelines, and of the Particular Conditions Which In- 
 crease or Decrease Their Propagation, by J. A. LePrince, 1915, No. 258, Malaria Control: Drainage as an 
 Antimalarial Measure, by J. A. LePrince, 1915, No. 272, Anopheline Surveys: Methods of Conduct and 
 Relation to Antimalarial Work, by R. H. von Ezdorf, 1915, No. 277, Malaria in the United States: Its Preva- 
 lence and Geographic Distribution, by R. H. von Ezdorf, 1915, No. 260, Control of Malaria: Oiling as an 
 Antimosquito Measure, by J. A. LePrince, 1915. 
 
 t" Mosquito Control in Panama," by J. A. LePrince and A. J. Orenstein, with an introduction by L. O. 
 HowRfd, New York. 1916. 
 
 14 
 
A PLEA FOR ORGAMZED ACTION 
 
 geological and soil surveys. As yet only a relatively small portion of the 
 Southern States has been completely surveyed in conformity to modern 
 topographic methods. For economic reasons it has seemed best to the 
 United States Geological Survey to give prior consideration to western and 
 northern states. Every community is individually interested, however, in 
 the exact ascertainment of local topographic features, which have a direct 
 and permanent relation to the mosquito and the malaria problems. Of 
 somewhat lesser importance is the a.scertainment of surface geologic 
 features, which in many sections of the South have been mapped by 
 state surveys with admirable accuracy and completeness.* This con- 
 clusion applies particularly to the surveys which have been made of the 
 coastal plains of Maryland, Virginia, North Carolina and Georgia. 
 Particularly good work in this direction has also been done by the State 
 Geological Survey of Florida. Soil surveys are of great practical im- 
 portance, and it is most fortunate that comjiaratively rapid progress has 
 been made in this direction by the Bureau of Soils of the United States 
 Department of Agriculture, and a large portion of the Southern States has 
 been mapped with reasonable completeness and attention to details. 
 These maps are of sj)ecial value in that they indicate the stream margins, 
 swami)S, j)onds, overfi(nved land, etc., which, broadly speaking, are the 
 underlying topographic conditions chiefly responsible for the local 
 frequency and relative intensity of malarial diseases. 
 
 No thoroughgoing analysis has been made of meteorological features, 
 which in all j>rol)ability, however, will be found to ha of secondary im- 
 portance. While there is prol)aI)ly a fairly constant correlation between 
 rainfall and malaria, nnich depends upon topographic features, tem- 
 perature, humidity and wind direction, aside from pro.ximity to the sea. 
 A very interesting investigation of the meteorology of malaria, reported 
 upon in considerable detail by Matthew D. O'Connell in the Journal 
 oj Tropical Medicine, emphasizes the urgency of an analysis in com- 
 plete detail of the temperature of the air, the drying power of the air 
 and the hourly Nclocily of the wind, and their possible correlation to 
 malaria, the object being to ascertain the atmospheric conditions which 
 raise the body temj)erature to a condition equivalent U) tiiermic fever, j 
 The view heUl by Dr. O'C'onnell is that malaria is nut eau.sed by mosquito 
 transmission or malaria parasites, and he refers to the relative absence 
 of malarial fevers from Fiigland at the present day as not to be explained 
 by the ])aueily of malarial parasites, since they an- imported in abun- 
 dance in the blood of soldiers, sailors and otherswhoare in\ alided home for 
 
 •A ulroiiK n|>|M'al for iiidiirviiiriil iiml <iu|>|Mirt in lirlinlf i>f nil rllorl to liriiii; iil><)iit llir nirly niniplrtioD of 
 the t<i|)oKrB|ihir iiiiip of lli<- I'liili-.l Slali-.s luLt l>r<ii .hi-hI duI liy n CDimiiillcf In Kxp'-itilr llin ('oiiip|rti,>ii of thr 
 Topot;r»pliir Mnp of llic I iiiird Slali-ii, of whirli I'rof. Willuun V. Dnvw. K<'oloKi«t, in Ihc r)iKiriiinn. Tim i« 
 (iriHTvinK of Ihr iiioiit lirnrly mipiiurt on t li<- part of all who arc inlrrrgilnl in Ihr ifirntific and rcunuiiiic tolutian 
 of till- prol>lrin of inalarin rriidiiiilion. 
 
 tAii inslrmtivr contriliulion <in">onir llnliilsuf Malaria not C'onlrolM l.y the MoMpiito" w • ' '• '-■I m 
 1901 hy Dr. Cliarlr* Mirkii, of Diililin, (in., illiiiilrati'il liy n ninp of Lniirrnn Connly, wlilili »ui{k*" '" 
 
 vnlur of lliuroiiKlily upcriali/.oii lo<al malaria ^lu<li«-<. A «oil iiirvry of l.iiiirrn<> <"oiinly »«< p., ', i..- 
 
 Kiirraii of Soil* iu lUlll, 
 
 15 
 
A PLEA FOR ORGANIZED ACTION 
 
 this disease from countries where they had contracted it.* He therefore 
 holds that "The absence of malarial fevers from England at the present 
 time can hardly be due to any scarcity of anopheles," and he concludes 
 that "it seems certain that malarial fevers have disappeared from Eng- 
 land without the employment of any antimalarial measures except the 
 drainage of marsh and fen land, and since the drainage of marsh and fen 
 land has not exterminated anopheles in England, it is difficult to under- 
 stand what caused the disappearance if they are spread by the mos- 
 quito." f It is, therefore, quite clear that qualified opinion is not yet 
 in entire agreement even regarding the causative factor in malarial 
 disease, and the researches of Dr. O'Connell are deserving of considera- 
 tion as suggestive of unrealized possibilities in the scientific study of 
 meteoi'ology in relation to this disease. As a practical question, however, 
 it may safely be said that thoroughgoing antimalarial measures, in- 
 volving the destruction of breeding-places of anopheles and the reduction 
 of the same to relatively unimportant proportions, have invariably been 
 followed by the eradication or substantial reduction of the disease. | 
 
 ^. The species of anopheles and other mosquitoes in the area affected by 
 malarial disease: It is not merely sufficient to ascertain the relative 
 frequency and species of anopheles, but it is advisable to include in a 
 thoroughgoing scientific survey the correct ascertainment of all the local 
 species of m.osquitoes, whether known to be malaria-carrying or not. The 
 elaborate investigations of the mosquitoes of North and Central America 
 and the West Indies by Howard, Dyar and Knab constitute a truly 
 monumental contribution to the cause of ultimate malaria eradication, 
 which rests fundamentally upon the prior ascertainment of the species and 
 relative frequency of mosquitoes of the malaria-carrying variety. These 
 researches have been made available through the Carnegie Institution of 
 Washington, in continuation of Dr. Howard's earlier investigations as 
 chief entomologist of the United States Department of Agriculture. 
 Mention requires to be made in this connection of the exceedingly useful 
 work in the same field by John B. Smith, State Entomologist of New 
 Jersey, published as a report of the New Jersey State Agricultural 
 Experiment Station, in 1904. S The report includes observations in 
 minute detail on the anatomy of mosquitoes, the habits of mosquitoes, 
 the processes of development and hibernation and finally the relation of 
 mosquitoes to disease, and practical considerations of checks and reme- 
 dies, including the natural enemies of mosquitoes, remedial measures 
 
 *The subject of marsh fevers as distinct, from ague in epidemic form is described by Creighton in his "History 
 of Epidemics in Great Britain," who also deals extensively with the whole subject of ague and its prevalence 
 in early times throughout England and Ireland. 
 
 fThe original articles by Dr. O'Connell were published in the Journal of Tropical Medicine, London, 19H 
 (Feb. 15, June 15, Aug. 15 and Nov. 15), 1913 (June 2, Sept. 1 and Dec. 1), 1914 (Nov. i), 1915 (May 1 and 
 Aug. 2) and 1916 (Mar. 15 and Dec. 15). 
 
 JFor a concise but comprehensive account of the practical results of antimalarial measures, see the 
 articles by special contributors for different countries of the world included in the treatise by Sir Ronald Ross 
 on the "Prevention of Malaria," New York, 1910. 
 
 ^Report of the New Jersey State Agricultural Experiment Station upon the Mosquitoes Occurring within 
 the State, Their Habits, Life History, etc., by John B. Smith, Sc. D., Trenton, 1904. 
 
 16 
 
A PLEA FOR ORG AM ZED ACTIOS 
 
 in general and destructive measures, as well as observations on mos- 
 quito campaigns. In the same field of practical economic entomology a 
 brief reference is called for to a bulletin on mosquitoes, by the Univer- 
 sity of the State of New York, as a contribution to the New York State 
 Museum, by E. P. Felt, state entomologist, including observations on 
 the distribution and abundance of mosquitoes, the migration by flight, 
 the methods of collecting and breeding, the haunts and breeding-places, 
 natural enemies and finally methods of control.* A strictly scientific 
 mosquito survey is, therefore, of the first importance in all local anti- 
 malarial measures, and without such a survey such measures are practi- 
 cally certain to fail. This, of course, requires the aid of voluntary 
 scientific assistants in the ascertainment of the prevailing species of 
 mosquitoes, whether malaria-carrying or not, in areas subject to malaria, 
 since it is a foregone conclusion that intensive investigations of this 
 kind can not be carried to a final conclusion by paid investigators alone. 
 The most practical suggestions with reference to the collection of mos- 
 quitoes have been j)ul)lished by the Museum of Natural History, of the 
 City of New York, but unfortunately the publication is out of print. 
 
 3. Anopheles 'propagation areas: The ascertainment of anopheles 
 propagation areas is, of course, another essential step in any and 
 every mosquito-eradication campaign. The breeding-places being known, 
 the methods of eradication become less difficult. It is absolutely 
 necessary, as shown in the experience which has been had on the 
 Isthmus of Panama, that all the breeding-places must be ascertained in 
 [)ractically minute detail. This means, however, that the area to be 
 made free from mosquitoes may be of rather limited extent, since any 
 and all efforts at general eradication over large areas are certain to fall 
 n)aterially short of the expected results. It is an error to assume that 
 the Panama Canal Zone has been made free from anopheles mosquitoes. 
 The coticliisioti api)li('s only to the iiihabilcd area and a relatively small 
 surrounding section. In the aggregate, perhaps, less than ten per cent, of 
 the entire Canal Zone has been brought within thoroughgoing methods 
 of moscjuito control and the equivalent malaria eradication. Obviously 
 the ascertainment of an()i)heles propagation areas is most difficult with- 
 out the aid of accurate topograi)hic and soil surveys. In any event, 
 such efforts are materially assisted by majjs showing, in complete detail, 
 the salient topographic and .soil features of the region under considera- 
 tion. The elimination of anopheles propagation areius is frecjuently a 
 most diflicwlt and often an expensive matter, but jus a general rule a 
 material reduction in malaria-carrying mos(initoes by means t)f the 
 elimination of propagation areas can be secured at moderate expense. 
 The essentials of such elimination arc .set forth by I/ePrince and Orcn- 
 stein, as follows: 
 
 (a) Attacks on propagation areas l)y filling. 
 
 ^Bulletin No. 79 of the New York SUte Muacum, Albany, 1904, "Ma«(|uitoPi or CiilioiJup <rf NVw York 
 SUte." I.y Eplirniin Porlor K.lt. 
 
A PLEA FOR ORGANIZED ACTION 
 
 (b) Attacks on propagation areas by drainage. 
 
 (c) Attacks on propagation areas by oiling. 
 
 (d) Attacks on propagation areas by larvacides. 
 
 (e) Attacks on propagation areas and adult mosquitoes by natural 
 enemies. 
 
 (/) Attacks on propagation areas by clearing bodies of water. 
 
 (g) Attacks on propagation areas by removal of jungle. 
 
 A full discussion of each and every one of these methods of attack lies 
 outside the plan and scope of this plea. It is self-evident, however, 
 that each and every method is governed by special local conditions, 
 which require to be ascertained by means of strictly scientific surveys, 
 including considerations of both malaria frequency and mosquitoes in 
 their relation to topographic features, meteorological conditions and 
 artificial circumstances, such as impounded waters, which have been 
 made a subject of special consideration in a report of the United States 
 Public Health Service. Each method of attack is thoroughly described 
 in the work of LePrince and Orenstein, and amplified by details of act- 
 ual experience and supplemented by statements of practical results.* 
 
 Most of the methods of attack on anopheles propagation areas involve 
 superior considerations of drainage and reclamation. It is, therefore, of 
 the first importance that there should be complete and hearty coopera- 
 tion between all local efforts at malaria eradication and the plans and 
 purposes of drainage commissions and other public bodies of an engineer- 
 ing character, chiefly, of course, such as have to do with the building 
 and control of waterways, levee-building, hydroelectric plants, etc. 
 
 4. Screening and practical destruction of adult anopheles in houses: 
 In the absence of measures and means for the practical elimination of 
 malaria-carrying mosquitoes as an essential prerequisite to malaria 
 eradication, the screening of houses and work-places is unquestionably of 
 very considerable value. Unless such screening, however, is complete, it 
 may be more of a hindrance than a help. Only the best kind of screens is 
 advisable for permanent structures. The 18-mesh screen is recommended 
 by the Panama sanitary authorities.! Special methods are urgently 
 advised in the case of railroad construction camps, and thoroughly well- 
 screened cars used for the housing of laborers should be insisted on by the 
 authorities. As observed by LePrince and Orenstein, "The crucial point 
 about screening is the thoroughness with which the work is done, and the 
 constant vigilance and care that must be exercised in speedily detect- 
 ing and remedying defects." They point out, however, that even "a 
 perfectly screened house may yet offer innumerable avenues for the 
 entry of mosquitoes," and they therefore, by inference, suggest the prior 
 importance of the complete destruction of anopheles propagation areas. 
 
 *0n the relation of impounded waters to the prevalence of malaria, two publications have been issued by 
 the United States Public Health Service, reprint No. 244, by H. R. Carter, and reprint No. 257, by J. A. 
 LePrince, Washington, 1915. 
 
 tThe subject of screening in relation to the practical destruction of adult anopheles in houses is fully 
 described in Chapter xv of LePrince and Orenstein's work on "Mosquito Control in Panama," 1916. 
 
 18 
 
A PLEA FOR ORGANIZED ACTIOS 
 
 5. On the possibilities of the reduction of domestic mosquitoes, a concise 
 treatise has been published by Edward Halford Ross, for the purpose of 
 providing instructions for the use of municipalities, tovm councils, 
 health officers, sanitary inspectors and residents in warm climates.* 
 After directing attention to the pathological importance of domestic 
 mosquitoes and restating the biological considerations of mosquito life 
 and propagation, Ross suggests as a first requirement "a fever census," 
 for he observes, "unless the state of health of the town is known before 
 the sanitary reform is begim it will be impossible to obtain comparative 
 statistics and there will be no means of showing what the results are." 
 Following the fever census, a further requirement is an approximate 
 estimate of the cost of mosquito reduction and an outline of the ways 
 and means to be followed. The financial considerations are, of course, 
 of the first importance in localities where extensive engineering 
 measures may be required. Accurate statistics of previous malaria 
 frequency are, therefore, necessary in support of the plea for continu- 
 ance of municipal or state expenditures made in behalf of mosquito 
 reduction and malaria eradication.! Ross warns against unnecessary' 
 extravagance, and he properly observes that, while mosquito reduction 
 is not an expensive measure, it can not possiiily be done for nothing. 
 The cost, of course, varies widely in diflerent localities, and no general 
 average unit of cost can be relied upon. The entire project of malaria 
 eradication, in his words, rests upon the fundamental principle "that it 
 is the duty of the state to undertake permanent reforms that lead to 
 health." Since erroneous conclusions are the rule rather than the ex- 
 ception, it is suggested that the ascertainment of local mosciuito density 
 be made during the period of maximum density, or immediately after 
 heavy summer rains. The extent of the water surface likely to be 
 utilized for breeding purposes should be ascertained, and at the same 
 time the number of garden fountains, water-butts, cisterns, ponds, 
 garden puddles and pools should be counted and "the presence of mos- 
 quito larvae or pupae in them ob.servcd" should be written down. A 
 house-to-house examination is absolutely essential, and without such an 
 in.sj)Cction,and reinspectioii and constant supervision, the sanitary results 
 of the Panama Canal Zone administration would have been impossible. 
 Granting, in the words of Kdward Ilallord Ross, that "the best larva- 
 cide for nios((uitoes is the abolition and prevention of stagnant water 
 collection," it is a foregone conclusion that the second best nu'tlio<l is the 
 more or less extensive use of oil. J 'J'he technical consideratioiLs of this 
 
 *"Tbe Krdurtion of Domntir MoiK|iiitor«," by Kclwnrd Halforil Hom, I'liilatirlphia, 1911. 
 
 tU<'fcrcncr iiiny nppropriati-ly hr inndi- to n Hicknr.w mirvcy of North Caroliiiii liy Ihr Ntrtropolilan Liff 
 Inxiirancc Compitliy, piil>luili<-fl in Ni-w ^ <irk, ll)ll>. Tin- rrmiltg of tliis mirvcy rnii iiol l><- n-linl ii|>oii (or thr 
 prrxrnt purposr, in that thr invrgliKntion wiui liiiiiir iliiriiiK thr iiionlh of .\pril. whrn malaria «.« thr ino«t 
 important di.iraac in thr roait roiinlirn wuuhl naturally l»c of a very much Iraarr drgrw of frrqucqi-y than 
 diirinK thr nioiilhii of Au)(>iit >nd Srptrmhrr. 
 
 Srr in thin coniintioii rrpriiil <I7 of thr I'nitrd Stale* Pulilir llralth Srrvir-r un "Moaquilor* anil Malaria 
 in Kojilrrn North Ciirolirin," liy Chnii. \V. Slilrs, WiixhioKton, ll>H. 
 
 (Thr Ki'iiTid ipiriitioii of oiliiiu nn nn nnliini><ii|iiito mraxiirr i* diariiiard by i. A. I^Prinrr in rriirinl 
 No. tm of the United Stulm riibjir llralth Srrvi<-r, WoahinKlon, IUI3. 
 
 19 
 
A PLEA FOR ORGANIZED ACTION 
 
 aspect of mosquito eradication are much more complete than is generally 
 assumed to be the case, and failure frequently has resulted from indiffer- 
 ence to fundamental considerations. Any and all of these aspects are much 
 more involved than is apparent upon supei'ficial consideration, and in its 
 final analysis the required results, if they are to be permanent, must rest 
 upon a thoroughly well-considered scientific plan of local health adminis- 
 tration and sanitary control. Wherever malaria has in part been eradi- 
 cated, as, for illustration, in certain localities of the Federated Malay 
 States, on the Panama Canal, on the Suez Canal and in Kiiartoum, the 
 results achieved have been in consequence of a thoroughly organized local 
 health administration, with sufficient powers to eliminate the risk of 
 flagrant individual violations of laws, rules and regulations intended 
 solely for the common good.* 
 
 Restating the conclusions of Edward Halford Ross, the plan of cam- 
 paign for the reduction of domestic mosquitoes may be summed up in the 
 axiom, which he suggests should be published broadcast : No stagnant uiater. 
 This axiom, when applied to the concrete problem of mosquito eradica- 
 tion, is, however, often an almost insuperable initial obstacle. The 
 exact ascertainment of all places where stagnant water exists, including 
 holes in trees, railway ditches, ornamental ponds, large and small water- 
 tanks, bilgewater on barges, etc., involves many practical difficulties. 
 As observed by Ross, "Thousands of mosquitoes may be produced from 
 a single saucer of water within three weeks, and neglect, therefore, in 
 matters of small detail may be followed by lamentable consequences." 
 As shown, however, in Panama and elsewhere, the practical eradication 
 of malaria is attainable at reasonable expense, and certainly so under the 
 less than semi-tropical conditions common to most of the Southern States. 
 In strictly tropical countries, with a very heavy rainfall and a very high 
 average range of temperature and humidity, the difficulties, of course, 
 are more serious. Even, however, under the most trying conditions of 
 extreme tropical life, results have been achieved which would have 
 been considered absolutely impossible even a few years ago. Mosquito 
 and malaria eradication efforts have occasionally failed, and even dis- 
 astrously so in some conspicuous instances, but the general principles \ 
 of radical measures are now so thoroughly understood that there is no 
 more reason for the endemic continuance of malaria than for that of 
 yellow fever, typhoid fever, cholera or plague, f 
 
 6. The most modern conceptions of malaria and the transmission of 
 dfsease were restated by Sir Ronald Ross, in his Huxley Lecture of 1914, 
 reprinted in the Scientific American Supplement for January 23, 1915. 
 After considering that it was only in 1880 that Laveran made the 
 
 •Permanent progress in malaria eradication depends, of course, in a large measure, upon sanitary progress 
 in general. The close relation of sanitary problems to many other medical problems is best illustrated in the 
 admiralile report, by Prof. W.J. Simpson, on Sanitary Matters in Various West African Colonies, published as 
 Parliamentary paper Cd. 4718, London, 1909. The results of effective sanitary measures are brought out in 
 the vital statistics of non-native officials serving in British West African colonies. The returns for 1914 were 
 issued as a Parliamentary paper, Cd. 7871, London, 1915. 
 
 tSee "Sanitation in Panama," by Wm. C. Gorgas, I\L D., New York. 1915. 
 
 20 
 
A PLEA FOR ORGAMZKD AiTIOX 
 
 important discovery that malaria was invariably associated with a minute 
 protozoal parasite of the blood, it is not discouraging that a larger meas- 
 ure of progress in malaria eradication should not have been achieved 
 during so comparatively short a period of time, considering the extensive 
 prevalence of the disease throughout the ages of the entire historic 
 period. Sir Ronald Ross properly refers to malaria as certainly the 
 most important disease in the tropics, and perhajjs in the world. Even 
 500 years B. C, he points out, the ancients were acquainted with the fun- 
 damental law of malaria — that is, its connection with stagnant water such 
 as marshes, etc., but even at the present time the population generally is 
 indifierent to stagnant water and promiscuously j)ermits the continuance 
 of breeding-places in localities and sections where it is perfectly obvious 
 that, l)ecause of such neglect and indifference, malarial disease is the 
 causative factor, directly or indirectly, of most of the ill-health afflicting 
 the community. Ross commenced his malaria investigations on the 
 theory of mosquito transmission at the suggestion of Sir Patrick Man- 
 son in 1896-1897, and in 1897 he finally correctly ascertained the true 
 causative factor in the disease. The discovery itself did not become 
 common knowledge until about 1898, so it is practically only about 
 eighteen years that the mosquito transmission of malaria has been gen- 
 erally accepted and generally understood.* Once that the principle was 
 clearly established, the conclusion, as summarized by Sir Ronald Ross, 
 became entitled to unconditional acceptance: "We now have a great 
 sanitary ideal put before us — so to manage our habitations, villages, 
 towns, and cities that the vermin in them shall be reduced to the lowest 
 po.ssible figures. Scores of entomologists and medical men are now 
 dealing exactly witii tiie habits of these creatures and showing us how to 
 effect the rcfpiired object. It demands only intelligence, energy, and 
 organization on the part of administrators. Unfortunately these quali- 
 ties are not always forthcoming, and administration often lags years 
 behind the dictates of science." f Regardless of all that is known con- 
 cerning malaria transmission through the moscjuito au<l the al)solute 
 urgency of effective measures of eradication and control, Sir Ronald Ross 
 is unhappily justified in his final conclusion that "Although fifteen years 
 have elapsed since many of the facts which I have described were dis- 
 covered, I think that I may say after constant study of the subject, and 
 with all due consideration, that iiianhirul h(t.s liillirrto not effected more 
 
 •An rxccptionnlly sufCRrstivr illustmlion of W\v most cfTocUvc diMcminnliun of I rust worthy information on 
 malnrin w to be found in nn o\itlino of I.-hh tlinn two pnK«'» in the "First (ourM- in Cirnrrnl Srirncr." hy F. D. 
 Bnrlxr iind otli.r!i. Hniry Molt & Co., Ntw York. lltKl. The most convenient Keiierul .li»rn.«ion of mulitria for 
 Iny readers is Fiirmeri' Hiiilitin t.'.O, isHiie<l l.y the Inited Stnles Depiirtment of Aitrieultiire. for Rrntuitous 
 .liHtril.iilion. entitled "Some Fa. Is Al.oul Maiiiria." l>y I.. O. Howard. I'h. D.. Wnsl.iiiKlon. lOKl. 
 
 tThn following lire the most iiseful^sourees of modern knowh-<lK'e re^ardinK niahirin with sperinl reference 
 1(1 tropical countries: "The Diseas.-s of Warm Countries." l.y H. Schenhe, Ixindon, ll)0.i, ".Manual of Tropical 
 M.-.licine."l,y(nslell»niaii.i(lialniers, <dj;d.. .New York. 10I.S. "Tropical Diseoses.a Manual of the Dineuesof 
 Warm Countries," I. V Sir I'alri.k Maiison. 5tli K.I. , New York. lIMi. "Tropi.al llyifienefor Resi.lenis inTropi. ..I 
 nn.l Sul.-Tropi.al Countries," l.y Sir I'ard.-y Lukis. .1.1 F..I.. ( al.ulta an.l U,n.loii. HMS. "Health I'reservation 
 in West Africa." I.v J. (has. Uvan. I^m.lon. lUl I. "The I'rinciplc, of HyKiene as Appli'd to In.pical an.l >ub- 
 Tropical Climntn." Ijy W. J. i{. .^imp.on. Loudon. lOOH, and the article "Molaria. " l.y U. H. von Ei.lorf. lo 
 II Hrferene«- Handbook of the Mrdiral Scicncri. Vol. vi. New York. 1010. 
 
 ^1 
 
A PLEA FOR ORGANIZED ACTION 
 
 than about one-tenth of the improvement of health ivhich it might have 
 effected already if it had put its heart into the business." 
 
 This is precisely the problem as it concerns the United States and, in fact, 
 the entire western hemisphere, wherever the incidence of malaria is of meas- 
 urable proportions at the present time. As observed by Major-General 
 Gorgas, in his address on the sanitary organization of the Isthmian 
 Canal as it bears upon antimalarial work, "though there has been muc? 
 antimalarial prophylaxis in the United States since anopheles have beer, 
 demonstrated to be the carriers of the plasmodium, this disease is yet far 
 from being eliminated, especially in the South," and he states with 
 reference to malaria eradication that "lack of success in any com- 
 munity must mean that the rnodus operandi has been inadequate 
 and imperfect, the fault generally being that details have been neglected 
 or ridiculed as too trivial for attention." As well said in the Scientific 
 American of December 7, 1912, with reference to the address of Dr. 
 Gorgas, "When malaria can be practically extinguished in such a region 
 as the Panama Canal Zone,* the same thing can be done practically 
 anywhere else," and Gorgas's fundamental principles, in the order of their 
 importance, are enumerated as "(1) the habitat of anopheles during the 
 larval stage is destroyed within a hundred yards of dwellings, since the 
 larvae of this mosquito live only in clear, fresh water, which is plentifully 
 supplied with grass and algae; (2) all protection for the adult mosquito 
 must be destroyed, since the adult is weak on the wing, not generally 
 flying far and needing plenty of grass and brush for protection against 
 the wind;t (3) all habitations are screened, but effectively, for screens as 
 ordinarily put up without expert supervision are of little use; (4) when 
 breeding-places can not be destroyed by drainage, the larvae must be 
 destroyed by means of crude petroleum, or some other larvacide." 
 These are principles not difficult of application, but they require an 
 active interest on the part of the community in clear realization of the 
 fundamental concept that the health of the nation is the wealth of the 
 nation, and that health squandered ruthlessly and recklessly is even 
 
 *The following table will show in an abbreviated form the very material reduction in the malaria mor- 
 bidity and mortality rate among Isthmian Canal Zone employees during the period of American construction. 
 The rates are subject to the qualification that they are based on the number of names on the payroll and not 
 on the true average number of persons employed. 
 
 Deaths from Malaria Hospital Cabks of Malaria 
 
 Average Number Rate per Rate per 
 
 Year of Employees Number 10,000 Employees Number 100 Employees 
 
 1906 26,547 233 87.8 21,739 81.9 
 
 1907 39,343 154 39. 1 16,753 42. 6 
 
 1908 43,890 73 16. 6 12,372 28. 2 
 
 1909 47,167 52 11.0 10,169 21.6 
 
 1910 50,802 50 9.8 9,487 18.7 
 
 1911 48,876 47 9.6 8,987 18.4 
 
 1912 50,893 20 3.9 , 5,623 11.0 
 
 1913 56,654 21 3.7 4,284 7.6 
 
 1914 44,329 7 1.6 2,886 6.6 
 
 1916 34,785 9 2.6 1,570 4.5 
 
 1916 33,176 3 0.9 493 1.5 
 
 fThe malaria morbidity and meteorological statistics of the Panama Canal Zone with special reference 
 
 to wind force indicate a pronounced negative correlation and apparently prove that the rate of incidence rises 
 
 or falls in inverse proportion to wind force. 
 
 22 
 
A PLEA FOR ORGANIZED ACTION 
 
 worse than the unpardonable waste of natural resources and accumu- 
 lated material possessions. As pointed out in an editorial of the Journal 
 of the American Medical Association on malaria and the development 
 of the South, after directing attention to the measures and means 
 adopted for the possible control of hookworm and pellagra, "Recent 
 agitation and information concerning these two diseases have placed 
 them in the limelight almost to the exclusion of the older and better 
 known disease, malaria, which is still a tremendous menace and handicap 
 to industrial progress." Attention is also directed to the interest in the 
 subject on the part of the Southern Medical Association, as shown by the 
 appointment of a special commission, of which Capt. Charles F. Craig, 
 of the Army Medical School, was made the chairman, and which, 
 among its membership, included Dr. C. C. Bass, the discoverer of the 
 method of cultivating the malarial plasmodium.* In concluding the 
 editorial, it was said that the work of this commission, which originated 
 wholly within the medical profession, should be of inestimable benefit to 
 the South, and that it should be encouraged and supported by the local 
 and national governments until malaria in the South had been as com- 
 pletely exterminated as yellow fever. This, it was held, was possible, but 
 a much greater and more expensive task than the eradication of the 
 former disease, and the burden of it should, therefore, be borne by the 
 whole people. The w^ork of the commission was tentative and incon- 
 clusive, because the necessary support, financial and otherwise, was 
 not forthcoming, nor was the required governmental cooperation, 
 whether federal, state or municipal, secured to the degree essential to 
 the attainment of substantial results. 
 
 The daion of a new era: It was in profound appreciation of these 
 facts that a new plan of procedure seemed advisable, and in fact neces- 
 sary, for the purpose of carrying into effect the following important 
 resolution unanimously adopted by the Second Pan-American Scientific 
 Congress : 
 
 The Second Pan-American Scientific Conerress, recognizing tliat the educa- 
 tion of the public in the elementary facts of malaria is of the utmost importance, 
 requests that — 
 
 The American Republics inaugurate a well-considered plan of malaria eradi- 
 cation based upon the recognition of the principle that the disease is prevent- 
 able to a much larger degree tlian has thus far been achieved. 
 
 It is said in the official text, in explanation of the resolution, that it 
 
 was pointed out, in the discussions of the section on Public Health and 
 
 Medical Science, that "in semi-tropical and tropical regions of the western 
 
 hemisphere the supreme importance of malaria as a problem of public 
 
 health was recognized })y all governmental, medical, and sanitary 
 
 authorities," and that "it was stated l)y competent authorities that the 
 
 economic loss due to the prevalence of malaria could be overcome by 
 
 diminishing the mortality; that the loss occasioned by mortality due 
 
 to malarial fever wius one of the most serious evils affecling the health 
 
 *A <on<iso prcscnlnlion of tlir K<'iii-ral iiiiilnrin prul>li'ni liy Cliiia. C Hiis.s wn.s coiilrilnilril to the Com - 
 mfmornlion Voliiim- of tlic AiinTicati Mnliciil Amiociutioii, CliicnKo, 1915. 
 
 is 
 
A PLEA FOR ORGANIZED ACTION 
 
 and happiness of the people, and that the problem [of malaria eradica- 
 tion] in all its aspects had not yet received the amount of public interest 
 and scientific investigation commensurate with its world-wide im- 
 portance."* This resolution, unanimously adopted by one of the most 
 important international gatherings ever held in the United States in be- 
 half of the furtherance of the cause of more amicable relations between the 
 American Republics marks a milestone in human progress, for it is 
 inconceivable that the nations which have pledged themselves to this rule 
 of action will ever prove neglectful of or indifferent to the principle thus 
 enunciated and the practical solution thus proposed, for the ultimate bet- 
 terment of living conditions throughout a vast portion of the western 
 world. All the fundamental elements of malaria eradication are now 
 thoroughly understood and they require only to be made public property 
 in the broadest possible sense. The apathy of governments and of 
 communities require to be shattered by an appeal to the conscience, the 
 intelligence, the self-interest of the people concerned. The elementary 
 facts of the disease are readily within the comprehension of even persons of 
 less than average intelligence, and they can be brought within the public 
 understanding, even on the part of school-children, as best illustrated by 
 the admirable manual published by the Philippine Board of Health, f A 
 common-sense descriptive account of the transmission of the disease by 
 malaria-carrying anopheles should be made available as a part of the 
 curriculum of every public school in the Southern States, and every 
 child should have accurate knowledge of the local species of disease-carry- 
 ing mosquitoes most detrimental to health and life.t Aside from the intel- 
 lectual interest thus aroused in the study of natural phenomena, the 
 child gradually would acquire an active and wholesome interest in the 
 broader questions of public health and sanitary science, for it is these 
 that will form the cornerstone of a better national life than we have 
 heretofore known, and through these that countless years of life will 
 be saved to the community, to the enormous social and economic ad- 
 vantage of all concerned. Measurable human progress consists not 
 only in the accumulation of material wealth, however vast, in inven- 
 tions, however marvelous, or intellectual attainments, however aston- 
 ishing, but as much, if not more, in the lengthening of human life, 
 in the elimination of needless disease, in the prevention of useless 
 accidents and in the consequential increase in real human happiness, 
 obtained through the realization of a distinctly higher level of genuine 
 civilization. § 
 
 *"The Final Act and Interpretative Commentary Thereon," Second Pan-American Scientific Congress, 
 by James Brown Scott, LL. D., Washington, Government Printing Office, 1916, p. 129 et seq. 
 
 tSee "Sanitary Inspectors' Handbook," by Carroll Fox, M. D., Government of the Philippine Islands, De- 
 partment of the Interior, Bureau of Health, Manila, 1913, pp. 64-67, 149, 163-164. 
 
 f'Malaria, Lessons on Its Cause, Prevention," etc., for use in schools, by H. R. Carter, United States Public 
 Health Service, Supplement No. 18 to the Public Health Reports, July 17, 1914, 3d Ed., Washington, 1916. 
 
 ^Considerable information of practical value in the study of the economic importance of preventive 
 medicine will be found in my address on "The Significance of a Declining Death Rate," Transactions First 
 National Conference on Race Betterment, Battle Creek. Mich., 1915. 
 
 24 
 
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PART II 
 
 A PLAN FOR ORGAxNIZED PREVENTION AND CONTROL 
 
 A well-considered working plan for the gradual eradication of 
 malarial diseases throughout the western henn'sphere must necessarily 
 be the result of an exceptionally qualified, active and continued interest 
 on the part of each and every member of the National Committee. 
 The following tentative plan, worked out in some detail, with a due 
 consideration of all the interests and activities more or less directly 
 concerned, may be found useful in the ultimate perfection of the final 
 program of the National Committee in the direction of a broadening 
 of the original plan and scope of the Committee's work as agreed upon at 
 a meeting held in the office of the Surgeon-General of the United States 
 Public Health Service at Washington on May 10, 191G. The charter 
 membership of the Committee is as follows: 
 
 I. Membership of the National Committee on Malaria 
 
 Dr. C. (/. Bass, Medir^al D<'j)art incut, Tulane University of Louisiana, New 
 Orleans, La. (Scientific Director of tho cxfX'rimental malaria eradication work in 
 Mississippi of the International Health Commission.) 
 
 Dr. Rupert Blue, Surtieon-CJeneral, United States Public Health Service, 
 Washington, D. C. 
 
 Dr. W. E. Britten, State Entomoloe:ist, Connecticut Agricultural Experiment 
 Station, New Haven, Conn. 
 
 Dr. H. R. Carter, United States Puiilic Health Service, United States Marine 
 Hospital, Baltimore, Md. 
 
 Capt. Chas. F. Craig, M. D., Medical Corps, United States .\rmy. Fort 
 Leavenworth, Kans. (Late memln'r of thi- United States Army hoard for tho 
 study of tropical fliseases in the IMiilip|)iiH;s urid author of ".Malarial Ft-vers," 
 New York, liKJO.) 
 
 Dr. Wni. H. Deaderifk, Hot Springs, .\rl<. (.Joint author, with Lloyd Thomp- 
 son, M. D., of "Eiuiemic Disea.ses of the Southern States," Philadelphia, lOH).) 
 
 Dr. W. K. Decks, (Jeneral Medical Superintendent, United Fruit Company, 
 New '^'ork City. (F^ormerly Chief of the Medical Clinic, Ancon Hospital, 
 Panama ( "anal Zone.) 
 
 Dr. Oscar Dowling, President of lh<' liouisiana State Board of Health, Now 
 Orleans, La. 
 
 Major-Oeneral W. C. Clorgas, United States Army, Wasljington, D. C. 
 
 Dr. Frederit'k R. Oreen, Si^cretary oflhe Ccmncil <ni Healthand Pulilic Instruc- 
 tion, .\meriean .Medical .Association, Chicago, III. 
 
 Dr. .Scale Harris. Editor of the Soul/urn Mniintl Journal, Hirtninghani, .\la. 
 Dr. Thomas .1. Ileadlee, ,Sl;ile Entomologist. N«'w Brunswii'k, N. J. 
 
 Dr. (Iraham K. Henson. .State Boanl of lleallh, .Faeksonville. Fla. (.Viithor 
 i)f "Malaria, Etiology, Pathology, Diagnosis, Prophylaxis," St. I^ouis. IDI.J.) 
 
 «7 
 
A FLAX FOR ORGAMZFD FRFAEXTIOX 
 
 Frederick L. Hoffman, LL. D., Statistician The Prudential Insurance Com 
 pany of America, Newark, N. J. 
 
 L. O. Howard, LL. D., Chief of Bureau of Entomology, United States Depart- 
 ment of Agriculture, Washington, D. C. 
 
 Mr. Arthur Hunter, Actuary The New York Life Insurance Company, 
 New York Cit3\ (President Actuarial Society of America.) 
 
 Dr. W. D. Hunter, Bureau of Entomology, United States Department of 
 Agriculture, Washington, D. C. 
 
 Dr. J. W. Kerr, Assistant Surgeon-General, United States Public Health 
 Service, Washington, D. C. 
 
 Dr. W. S. Leathers. Director of Public Health, Jackson, Miss. (Administra- 
 tive Director in charge of the malai'ial eradication work in Mississippi of the 
 International Health Commission.) 
 
 Mr. Joseph A. LePrinee, C. E., A. M., United States Public Health Service, 
 New Orleans, La. (Late Chief Sanitary Inspector, Isthmian Canal Commis- 
 sion, and author of "Mosquito Control in Panama," New York, 1916.) 
 
 Dr. Charles F. ISIason, Medical Corps, United States Army. (Late Chief 
 Health Officer, Panama Canal Zone.) 
 
 Dr. J. Y. Porter, State Health Officer, Jacksonville, Fla. 
 
 Dr. W. S. Rankin, State Health Officer, Raleigh, N. C. 
 
 Dr. M. J. Rosenau, Harvard Medical School, Boston, Mass. (Author of 
 "Preventive Medicine," New York, 1913.) 
 
 Dr. E. R. Stitt, Medical Inspector, United States Navy, Washington, D. C. 
 
 Dr. John M. Swan, Rochester, N. Y. (Secretary American Society for Tropi- 
 cal Medicine.) 
 
 Dr. W. S. Thayer, Baltimore, Md. (Joint author, with John Hewetson, 
 M. D., of "The Malarial Fevers of Baltimore," Johns Hopkins Hospital Reports, 
 1895, and author of "Lectures on the Malarial Fevers," New York, 1897.) 
 
 R. H. von Ezdorf, Surgeon, United States PubUc Health Service, New Orleans, 
 La. (Since deceased.) 
 
 Dr. Robert Wilson, Jr., President of the South Carolina State Board of 
 Health, Charleston, S. C. (Late President of the Southern Medical Association.) 
 
 II. General Plan of Organization 
 
 The administrative direction of the work of the Committee is to be in 
 charge of an Executive Committee, consisting of an Honorary Chair- 
 man, an Active Chairman, a Secretary and the Chairmen of the 
 Subcommittees, a majority of whom shall constitute a quorum. 
 
 It is recommended, but at present not provided for, that state com- 
 mittees be formed in each and every state in which malaria exists as a 
 serious public-health problem. 
 
 The general objects, plans and purposes, and the organization of the 
 National Committee, in detail, as agreed upon at the Washington 
 meeting on May 10, 1916, are as follows: 
 
 Objects of the Committee. The plan and scope of the Committee shall be : 
 (a) To stimulate the scientific and public interest in malaria problems. 
 {h) To serve as a medium through which societies and individuals 
 
 may become identified with the study and prevention of malarial 
 
 diseases. 
 
A PLAX FOR ORG AM ZED PRFA'EXTfOX 
 
 (r) To coordinate the efforts of these agencies with those of consti- 
 tuted federal, state and local authorities. 
 
 Character of the Organization. The Committee shall be a voluntary 
 organization, its members shall ser^'e without compensation, and there 
 shall be no membership dues. 
 
 Membership. Persons who have accepted membership (at the time of 
 organization) shall be known as charter members. 
 
 The executive officers of the state boards of health of states in which 
 malaria exists as a serious public-health problem and state officers 
 charged with the enforcement of laws for the suppression of disease- 
 bearing mosquitoes are invited to become members of the Committee. 
 Others interested in the objects of the Committee may from time to time 
 become members by vote of the Committee. 
 
 Meetings. There shall be a meeting of the Committee held once 
 annually at the call of the Chairman at such time and place as he may 
 deem most suitable. Special meetings may be had, however, on the 
 call of the Chairman. 
 
 Officers. The executive officers elected at the meeting on organization 
 arc Honorary Chairman, Major-General W.C. Gorgas, ActiveChairman, 
 Dr. Rupert Blue, and Secretary, Dr. Scale Harris. 
 
 riie work of the National Committee is divided among the following 
 six subcommittees: 
 
 (1) Administration. 
 
 (2) Kiitomology. 
 
 (3) Medical Research. 
 
 (4) Kducation and Publicity. 
 (.')) Sanitary Engineering. 
 (6) Statistics. 
 
 HI. General Functions of Subcommittees 
 The specific functions of the subcommittees, in detail, are given 
 
 below : 
 
 Administration. The duties of this comnnttee shall be to encourage: 
 (1) The organization of the state committees in afliliation with the 
 
 National Committee 
 
 ("i) The adoption of antini.il;iri;d iiicasurcs by coMiiMMnities. 
 
 ('J) Malarial surxcys aiid (jciiioiisl ral ion of ant iiiialarial work in 
 
 suitable communiti(*s. 
 
 (4) Cooperative effort in malarial wmk. 
 
 Kntomologtf. The duties of this coMuiiit Ire shall be to nicotirage: 
 
 (1) Mosfjuito surveys. 
 
 (2) Moscjuito collections. 
 
 (.S) Studies of entomological factors iij the nial;iri;i problem. 
 (4) Mosijuilo bionomics. 
 
A PLAN FOR ORGANIZED PREVENTION 
 
 Medical Research. The duties of this committee shall be to encourage : 
 
 (1) Studies of the life history of the malarial parasite. 
 
 (2) Its effects oii man. 
 
 (3) Means for its destruction in man. 
 
 Education and Publicity. The duties of this committee shall be: 
 
 (1) To encourage the teaching of the facts of malaria and its control 
 in the schools and as far as may be possible to standardize the subject- 
 matter and the methods of so doing. 
 
 (2) To encourage the discussion of malaria in medical societies and 
 other interested bodies. 
 
 (3) To arrange for popular lectures on malaria to adults and to 
 school-children. 
 
 (4) To interest the public press and encourage it to carry on publicity 
 campaigns on malaria. 
 
 Sanitary Engineering. The duties of this committee shall be : 
 
 (1) To encourage the employment of skilled sanitary engineers by 
 communities contemplating drainage and other engineering measures 
 for the control of malaria. 
 
 (2) To confer with those engaged in drainage or impounding projects, 
 so as to obviate the establishment of disease-breeding areas. 
 
 Statistics. The duties of this committee shall be: 
 
 (1) To encourage states and minor civil divisions to record and 
 report cases and deaths from malaria by localities. 
 
 (2) To standardize methods of tabulation to be used for this purpose, 
 
 (3) To encourage the collection of data relating to the economics of 
 malaria. 
 
 IV. Ways and Means 
 
 In the furtherance of the objects and purposes of the National Com- 
 mittee on Malaria Eradication, it would seem urgently advisable that 
 there should be introduced into Congress a bill making provision for 
 adequate federal support on a cooperative basis, more or less in con- 
 formity to an act of the Sixty-third Congress, which provides for co- 
 operative agricultural extension work. The sanitary cooperative act 
 may be made all inclusive or specifically limited to malaria eradication 
 and control. If made all inclusive, the basis should be on the principle 
 of proportionate contributions, with a due regard to both area and rural 
 population.* No federal financial support should be forthcoming until 
 the states and counties concerned have provided twice the amount 
 required. In other words, if the federal appropriation, on the basis of 
 a given population, for a given area is, say, $10,000 per annum, this 
 amount should not be available until $20,000 has been provided through 
 the local authorities. Since rural sanitation generally is so very closely 
 
 ♦Recommendation based on original suggestion by Dr. W. S. Rankin at Southern Health Officers' Confer- 
 ence, Washington, D. C, January 29, 1917. 
 
 30 
 
A PLAy FOR ORGANIZED PREVEXTWX 
 
 related to malaria eradication, at least in the Southern States, it would 
 probably be advisable, as a practical consideration, to make the con- 
 gressional appropriation available for sanitary purposes generally, 
 rather than for malaria eradication alone. The general supervision of 
 such federal expenditure should, of course, be under the direction of the 
 Surgeon-CJeneral of the United States Public Health Service, who should 
 make the federal allotment upon the recommendation of the Governor 
 of the State and the Secretary of the State Board of. Health, after the 
 required local ajjpropriation had been provided for. In the words of 
 the Secretary of Agriculture, "the Extension Act is one of the most 
 striking educatioiud measures ever adopted by any government," but 
 of even greater practical importance would be a sanitary extension 
 act especially applicable to rural communities. The Agricultural 
 Extension Act not only provides for active cooperation between the 
 states and the federal government, but "it guarantees a coordination of 
 the two forces of the two jurisdictions. It places the brains of the two 
 great agencies in conjunction, eliminates waste and friction, and insures 
 efficiency." The act provides for a gradually increasing appropriation 
 without any further legislation. Considering the enormous practical 
 value of such legislation in the furtherance of intelligent agricultural 
 development, it re(|uires no argument to sustain the conclusion that 
 a similar extension act in the direction of sanitary and general 
 |)ublic-health i)roblems would prove productive of far-reaching 
 results to the i)ul)lic at large. Every state in the I'nion through its 
 [)roper authority has accepted the provisions of the Agricultural Ex- 
 tension Act, and it is a foregone conclusion that there would be a similar 
 C(>oi)eration on the part of all of the states in regard to the plan of 
 federal and state sanitary cooperation. Aside from such direct financial 
 sui)i)()rt in the de\el(»i)m<Mit of rural sanitation, it is urgently to l)e desired 
 that a sufficient amount should be nuide a\ailal)le to the l'\'dcral I'ublic 
 Health Service for malaria research and demonstration work. An 
 aj)proi)riation of not less than $100, 000 [)er anmnn should be made as a 
 guarantee for the continuance of the admirable work which is at present 
 being done by the l''ed(M-al I'ublic flealth Ser\ice in this important 
 direction. Malaria as a publi(!-health problem is of such vast im- 
 portance to the Nation, that it uiiglil also be considered n(lvisal)le to 
 pro\ide for the establishment of a permanent Federal Board for Malaria 
 l'>radication, consisting of the Surgeon-( ien<'ral of the I iiited States 
 Army, the Surgeon-Cieneral of the I'nited States I'ublic Health Ser\ ii<' 
 and the Secretary of the Department of .Vgrioilture. 
 
 Of special interest in coimcclion with this suggestion is the enactment 
 of a law (liHi) by tlu* Sixty-fourth Congn'ss providing for federal aid to 
 the states in the const ruction of rural post roads and for other purposes. 
 The initial uppr(»priation under this act is ^.'i.OOO.OOO; for the y(>ar 
 IQlHthesum apjjropriated is $10,000,000; for the y«'ar 1!)!!). $l.i.OO0.000; 
 
 81 
 
A PLAX FOR ORGANIZED PREVEXTIOX 
 
 for the year 1920, $20,000,000, and for the year 1921, $25,000,000. The 
 federal appropriation to the states becomes available on the required 
 amount being certified to by the State Highways Department and the 
 State Governor. Any state desiring to avail itself of the benefits of this 
 act through its State Highways Department is required to submit to the 
 Secretary of Agriculture such a project statement, setting forth the 
 proposed construction of any rural post road or roads, service, plans, 
 specifications and estimates, as the Secretary of Agriculture may require. 
 In much the same manner an appropriation for federal sanitary 
 cooperation could be carried into effect under the immediate direction of 
 the Federal Public Health Service, the State Board of Health and the 
 State Governor. 
 
 V. Federal Departmental Cooperation 
 The keynote of an active federal campaign against malaria is the clear 
 recognition of the supreme importance of the most effective and active 
 cooperation of federal governmental department chiefs, including among 
 those essential to the purpose: 
 
 (a) The Surgeon-General of the United States Army, 
 (6) The Surgeon-General of the United States Navy. 
 
 (c) The Surgeon-General of the United States Public Health Service. 
 
 (d) The Chief of Engineers of the United States Army. 
 
 (e) The President of the Mississippi River Commission. 
 (/) The Director of the United States Geological Survey. 
 (g) The Director of the United States Reclamation Service. 
 
 (h) The Director of the Office of Public Roads and Rural Engineering. 
 
 (i) The Chief of the United States Weather Bureau. 
 
 ( j) The Chief of the United States Bureau of Soils. 
 
 (k) The Chief of the United States Bureau of Entomology. 
 
 (/) The Chief of the United States Bureau of Fisheries. 
 
 (m) The Chief of the Division of Vital Statistics United States Census. 
 
 (n) The Chief of the States Relations Service. 
 
 (o) The Federal Farm Loan Board, 
 
 (p) The United States Commissioner of Labor Statistics. 
 
 VL Pan-American Cooperation 
 
 In view of the fact that the official text of the resolution of the Second 
 
 Pan-American Scientific Congress (Article 39) suggests that 
 
 The American Republics inaugurate a well-considered plan of malaria eradica- 
 tion, based upon the recognition of the principle that the disease is preventable 
 to a much larger degree than has thus far been achieved. 
 
 It is implied and required that there should be the most hearty 
 cooperation between the American Republics as officially represented in 
 the United States by the Director-General of the Pan-American Union, 
 particularly in the direction of the most effective publicity of all impor- 
 tant matters relating to the suggestions and recommendations of the 
 National Committee for the information of the Latin-American countries 
 
 32 
 
A FLAX FOR ORGAMZFJ) FRFA'FXTIOX 
 
 through the medium of the Monthly Bulletin of the Fan- American 
 Union. In addition thereto, the assistance of the Chief of the Division 
 of Latin-American Affairs of the Department of State might be enlisted 
 in behalf of an efl'ort to bring about the cooperation of the American 
 Republics agreed upon as desirable and essential in the resolution re- 
 ferred to. It is, furthermore, self-evident that the subject of malaria 
 eradication should engage the most serious attention of the International 
 Sanitary Congress at its fortlicoming session and that adequate pro- 
 vision should be made sufficiently in advance to provide for the most 
 thorough scientific consideration of the problem of malaria eradication 
 in its international aspects at the Third Pan-American Scientific Con- 
 gress agreed upon to be held in Lima, Peru, in 1920.* 
 
 The first of the ]*an-American (jovernments to make provision for 
 malaria eradication is the Republic of Peru. According to a recent law- 
 passed by the Peruvian congress and approved by the president, subse- 
 quently to be enlarged upon by state regulations, malaria-eradication 
 measures will be classified in four sections, namely, the treatment of 
 patients, the i)rotection of people living in places where malaria is 
 recognized as endemic, the destruction of mosquitoes and the drainage 
 or special treatment of swampy lands. According to a report of the 
 JJuroau of Domestic and Foreign Commerce, the Peruvian (io\ernment, 
 in connection with the antimalaria cami)aign, "will import annually 
 such a (piantity of (juinine as may be considered necessary, and this 
 drug will be imported free of all customs duties and port charges. 
 Individuals and institutions may purchase rjuininc of the (lovernmcnt 
 at cost jjrice for their own use and for the treatment of persons under 
 their charge. .\11 i)roj)rietors of estates, all railways, corporations, and 
 other organizations enii)loying labor are under obligations to furnish 
 medical assistance to their employees, either directly or through pro- 
 I)ortionate contributions to charitable dispensaries, and insp<*clors will 
 i)e ap|)ointed to see that this part of the work receives due attention. 
 I'nemployed persons will receive free quinine from the (iovernment. 
 For the protection of |)crsons living in swampy districts, houses nuist be 
 ecjuijiped with mos(|uilo-proof netting, and rice or other crops re<|uiring 
 flofxling nuist not be cultivated within a ccrfain distance of habitations." 
 
 According to the same report the Peruvian (ioxcrnmenl "will at once 
 begin the work of draining the lands where malaria is most prevalent, 
 and all private owners are given from one to four years lo complete the 
 sanitation (»f their hmds. When- drainage is impracticable, swamps 
 are to be treated with crude petroleum to destroy insects and their 
 larvae, 'i'he (i()V<*rnment is authorized to give prizes and honors to 
 
 The plan and Kiipc uf tlir work of thr Inlrrnulional IIIkIi CotiiDiiwion Ho do( at prrtriil proviilr (or Ihr 
 conai<lrrH(ioii of brnllli iiml (iinilnry prol<|rtiii. Il woulil irrm clr»irnli|r to inrrrax' the final pr<i);rani of th<" 
 comnii.ijiion hi net (urlli in lli<- rrporl n( llir Tnili-d Shilra Srrtion on tlir fimt itrnrrnl nirrliiiK. Ii'ltl at lliirno* 
 Aim, April 3 to \i, lllld, liy Ihr lulilitinn of n (oiirtPrnth irrlion, on I'liMir ili-nlth nml IntrrnBliimal Qiiaran- 
 linr. Hy mrana of iinrli a urction tlir iiilijrct of malaria rrailii alinn in it* I'Mn-Anirriian aaprri* would hr 
 appropriatrly IitoukIiI lo Ihr attrnlion of the rr»pr< livr itovrrnnirnl* contrrnrd and |H>uildy rarlirr tlian at 
 thr inrrtinK of th<' lliini I'liii-AnK'riian Si iinlilii Conitrrii*, in IIWO. 
 
A PL AX FOR ORG AM ZED PRFA^EXTION 
 
 proprietors who show the most zeal in putting their lands into good 
 condition. An exhaustive study is to be made of modern irrigation and 
 cultivation systems, with a view to overcoming the farming conditions 
 that lead to malaria. In addition, a course of study on the prevention 
 of malaria is to be introduced in all the public and private schools of 
 Peru. This instruction, as well as the organization and maintenance of 
 the sanitary work, will be in charge of the Department of Public Health, 
 and the expense incurred wnll be met by annual appropriations in the 
 budget." 
 
 The Peruvian Government is entitled to the high honor of having been 
 the first of the Pan-American Republics to carry into actual effect the 
 provisions of Article 39 of the Final Act of the Second Pan-American 
 Scientific Congress, and the results to be achieved under the contem- 
 plated measures of eradication should make a most useful and instruc- 
 tive contribution to the proceedings of the Third Pan-American Scientific 
 Congress, to be held in Lima, Peru, in 1920. 
 
 VII. State Cooperation 
 
 On the part of each of the states most seriously interested in malaria 
 eradication, the problem in its final analysis is chiefly a matter of 
 local concern, and the required funds for such objects and plans as 
 may be deemed advisable must be derived from state and local rev- 
 enues, except in so far as they may be amplified by corresponding 
 amounts made available through federal appropriations.* It is, how- 
 ever, essential that there should be on the part of each and every state 
 directly concerned the most thoroughly considered cooperation on the 
 part of 
 
 (a) The State Board of Health. 
 
 (6) The State Engineering, Drainage or Reclamation Commission. 
 
 (c) The State Geological Survey. 
 
 (d) The scientific departments of the State University, useful in the 
 rendering of assistance in the furtherance of the plans of the National 
 Committee. 
 
 (e) The State Agricultural Experiment Station. 
 (/) The State Medical Society'. 
 
 VIII. County and Municipal Cooperation 
 
 Malaria, in general terms, being largely a local problem, particularly 
 as regards mosquito eradication, it is of the utmost urgency that the 
 most carefully considered cooperation should be had on the part of the 
 counties and municipalities in which malarial disease is known to prevail 
 
 *This suggestion is merely tentative. The underlying consideration is the excellent work of the States 
 Relations Service of the United States Department of Agriculture, which represents the Secretary of Agri- 
 culture in his relations with Stale Agricultural Colleges and Experiment Stations, under the acts of Congress 
 granting funds to these institutions for experimental and cooperative extension work in agriculture and home 
 economics, in carrying out the provisions of act-i of Congress making appropriations to this department for 
 farmers' cooperative demonstration work, investigations relating to agricultural schjols, farmers' institutes 
 and home economics, etc. 
 
 34 
 
A PLAX FOR ORGANIZED PREVEXTIOX 
 
 to a more or less serious degree. It is therefore suggested as essential 
 that the cooperation of the following should be enlisted: 
 
 (a) The City or County Board of Health. 
 
 (b) The City or County Engineer. 
 
 (c) The Department of Public Works or kindred bodies having to 
 do with sewerage and drainage. 
 
 (d) Local medical societies. 
 
 IX. International, National and Corporate Health-Promoting 
 
 Agencies 
 
 In addition to fedoral, state and local governmental cooijcration. all 
 of the more imj)ortant international, national and corporate health- 
 promoting agencies should be utilized in the furtherance of the practical, 
 as well as theoretical, work of the National Committee. Of these 
 agencies, the following are of special importance: 
 
 (a) The International Health Commission (already actively engaged 
 in malarial research and eradication in certain Southern States).* 
 
 (b) The Carnegie Institution (which has rendered a most conspicuous 
 service to the cause of malaria eradication by the publication of a 
 thoroughly scientific treatise, in four volumes, on "The Mos- 
 quitoes of North and Central .Vmerica and the West Indies," by 
 Leland O. Howard, Harrison G. Dyar and Frederick Knab). 
 
 (c) The American Public Health Association, especially through the 
 Section on Sanitary P^ngineering. 
 
 (d) The Southern Sociological Congress. 
 
 (e) The American Medical Association. 
 (/) The Southern Medical Association. 
 (g) The American Academy of Medicine. 
 
 (h) The American Climatological Association. 
 
 (i) The American .Ysstxrialion of Kconomic Entomologists. 
 
 (j) The American Micro.scopical Society. 
 
 (k) The American Nature Study Society. 
 
 (/) The .XmericaM Society of Civil Engineers. 
 
 (w) The American Museiun of Natural History. 
 
 (") The American Hospital A.ssociation. 
 
 •Kxlr»ct from Srcond Anniinl RrjMirl of thr IntrrnBtiotikl llrnlth Commiuion. 1018: 
 
 "Throretif«Ily. the control of mnlnria is rrlativrly limplr, l>iil aji > prarliml iiti'lrrtakinf it ha* b«*n 
 found rxtmnrly iliflicull. In virw of thr important intrrrstf at stakr, howrvrr, thr Intrrnational llrajtb 
 CommiMion in iinilrrtakinx to rarry out an ri|MTiinrnl with a virw to ascrrtaininK what .Ir^rrr of control may 
 be achirvrd in our Irmprralr climntr within thr liniit.i of rrajunatilr rx|M-niliturr an<l umlrr '' ' •• 
 
 which prevail in typirnl furmiiiK •■oiiiniunilirg in thr >(iiithrrn >t«lr». Arrniitfrnirnli havr \>rrn > 
 
 out two »rls of rx|H:riinrn(s, onr lo lint thr prn<-ti<'nliillt.v of ninlaria lonlrol \>y <|rlrrtin(l thr rarr - 
 
 lag thrm of thr parasiira; and thr othrr to trat thr prartirahility of malaria runlrul by mean* u( a >umt»aa- 
 tioo of control mraaurr*. In nrilhrr raar ii the rxlrrmination of moafjuitora by major drainafr oprratiou to 
 b* undrrtakrn." 
 
 S5 
 
A PL AX FOR ORG AM ZED PRFA'KXTIOX 
 
 X. Education and Publicity 
 
 Since all measures and means for malaria prophylaxis must rest 
 primarily for their highest obtainable degree of effectiveness upon the 
 intelligent, most hearty and continued cooperation of the general public,* 
 it is of the first order of importance that qualified assistance should be 
 rendered in behalf of this effort by 
 
 (a) The United States Bureau of Education. 
 
 (6) The state, county and municipal educational authorities. 
 
 (c) The Council on Health and Public Instruction of the American 
 Medical Association. 
 
 (d) The General Federation of Women's Clubs, 
 
 (e) The press, whether general, medical or technical, including period- 
 icals and the general press service of the Associated Press, the 
 American Press Association, the International News Service, the 
 United Press Association, etc. 
 
 (/) The mosquito extermination associations. 
 
 (The New Jersey association has held four annual meetings to 
 date and has rendered conspicuous educational services. Thc^ 
 proceedings are a most valuable source of useful information. 
 According to an address by Dr. Ulrich Dahlgren, the number o { 
 cases of malaria in Princeton, N. J., was, in consequence of loca I 
 antimalarial measures, reduced from 127 in 1914 to only 8 ii i 
 1916.) 
 
 XI. Industrial and Other Corporate Business Organizations 
 
 (a) The Chamber of Commerce of the United States of America 
 (This body has already indicated its interest in the subject, by 
 the publication of a special bulletin on "Reclamation of Swamp 
 Lands and Conquest of the Malaria-bearing Mosquito," Wash- 
 ington, D. C, October 27, 1916.) 
 
 (6) Local chambers of commerce and boards of trade. 
 
 (c) The Southern Commercial Congress. 
 
 (d) The National Civic Federation. 
 
 (e) The National Farmers' Congress. 
 
 (/) The National Rivers and Harbors Congress. 
 
 ig) The Atlantic Deeper Waterways Association. 
 
 (h) Southern railway companies and river transportation lines. 
 
 (i) Steamship companies engaged in Southern coastwise or Latin- 
 American commerce. 
 
 ( j) Life insurance companies and societies transacting business in the 
 Southern States and Latin-American countries. 
 
 (k) The Life Extension Institute. 
 
 ♦Of considerable practical value is a brief "Summary of Facts Regarding Malaria Suitable for Public 
 Instruction," by Maj. (now Sir) Ronald Ross, published by John Murray, London, 1911. This summary 
 includes a descriptive account of the relation of the parasites to malaria, the mode of infection, the essential 
 facts about mosquitoes, the means of personal prevention and the means of public prevention. The outline 
 concludes with the suggestion that "for further information or assistance the reader should apply to the local 
 tanitary or medical authorities." 
 
 3G 
 
A PLAS I'ORORCAMZEI) PRFA'K.\TI(}.\ 
 
 XII. An Active Advisory Council 
 
 An active advisory council might be formed and made to consist 
 of official representatives of the foregoing and kindred bodies or organiza- 
 tions and agencies useful for the purpose of furthering by their active 
 ©operation or by means of correspondence, etc., the plans and purposes 
 of the National Committee on Malaria. The council should meet with 
 the National Committee at least once a year in the city of Washington, 
 so as to bring about the most satisfactory coordination of federal, state 
 and other interests. 
 
 XIII. Some General Methods of Procedure 
 
 A. Malarial Surveys and Public Education 
 
 Among the more important methods and means in behalf of active 
 eflForts at malaria eradication the following are deserving of special 
 consideration : 
 
 (a) Malaria and mosquito surveys. For an excellent illustration, see 
 Bulletin 189, Connecticut Agricultural Experiment Station, en- 
 titled "A Mosquito Survey at the Mouth of the Connecticut 
 River." The special importance of this survey is that the ex- 
 pense of making the same was met by the Old Saybrook Town 
 Improvement Association of Old Saybrook, Conn. 
 
 One of the most instructive of the many mosquito surveys 
 made in this country is the Report on Mosquito Investigations, 
 by W. E. Britton and Harry Viereck, in the Connecticut Experi- 
 ment Station Rej)ort for 1904, including observations on tlie char- 
 acteristic vegetation, as a guide to the ascertainment of mosquito- 
 breeding areas, and descriptive accounts, illustrated by maps, of 
 the most affected area^s in the state. The rei)ort concludes with 
 practical suggestions on mosquito control in Connecticut and 
 on the relation of nio.squitoes to proi)erty values. 
 
 An excellent account of modern methods in making anopheles 
 surveys, with extended lists of anopheles breeding-places through- 
 out different health districts of the colony, is et)ntained in the 
 Trinidud Malarial ]^'po^l for 1 !> 11-1 !)!."), by Dr. C. F. Lassalle/i'riii- 
 idad, 1!)1(>. Nine diflerent types of breeding-areas are defined, as 
 follow.s: (1) Slowly running water-courses, streams and rivers, 
 i'i) I'ools in ravines ravines are water-courses which are generally 
 dry during the dry season and contain pools during the rainy 
 season. (3) l/ow-lying swampy and grassy land bordering on 
 extensive mangrove swamps — containing large and small depres- 
 sions, crab-holes, etc., (4) Rice fields, (.5) I*onds, ((J) Shallow wells 
 and water-holes, (7) IJorrow-pits at tin- sides of roads and railwa\ 
 lines, (H) "Tapia" holes holes from wlii«li cliiy is obtained for 
 building huts, (ft) Earthen street and road drains improperly 
 graded or blocked. Of s|(ccial pracli<id inten-st are tin" fornix 
 
A PLAN FOR ORGANIZED PREVENTION 
 
 used in the anopheles survey of Trinidad and the instructions to 
 assistant sanitary inspectors. 
 
 (b) Malarial indices, primarily of children, through the medium of 
 medical school inspection and of factory employees through the 
 physical examination of applicants for work. 
 
 Some interesting observations on the methods of obtaining 
 children for spleen examinations, and the practical difficulties 
 to be overcome, are included in the notes on Sumatra in Malcolm 
 Watson's treatise on "Rural Sanitation in the Tropics." In the 
 same work is a brief discussion of erroneous or misleading spleen 
 rates in correlation to malaria death rates in British Guiana. The 
 most important recent contribution to this subject is "The Spleen 
 Census for 1914," of the island of Trinidad, by C. F. Lassalle, 
 acting assistant medical officer of health, in the Trinidad Malarial 
 Report. According to this census the percentage of children with 
 enlarged spleens in the colony was 14.1 per cent. The corre- 
 sponding percentages obtained for other countries, as given in the 
 report, for comparatively recent years, are 34.1 for Mauritius, 
 34.1 for Ceylon, and 17.9 for Trinidad and Tobago, during 1913- 
 1914, which, therefore, indicates a decline during the year 1914, 
 when the ascertained percentage, as previously stated, was 14.1. 
 The maximum spleen rate in 1914, for the Oropouche and 
 La Brea districts, was 57.7 per cent. The lowest rate prevailed 
 in the Arima district, or 1.1 per cent. A brief but exceptionally 
 useful practical contribution to American malarial index work is 
 reprint 159, by the late R. H. von Ezdorf, M. D., of the United 
 States Public Health Service, Washington, 1914. 
 
 (c) Public education, chiefly through the public schools, more or less 
 in conformity to the essential principles of "Malaria, Lessons on Its 
 Cause and Prevention," by Dr. H. R. Carter of the United States 
 Public Health Service, and the broad outlines of malaria prevention 
 as laid down in Bulletin No. 10 of the Medical Series of the 
 University of Missouri,- by Prof. Elbert L. Spence. 
 
 (d) Medical education, in the furtherance of improvements in clinical 
 and microscopical diagnoses of malarial disease, in the more 
 accurate differentiation of the several types of malaria and accu- 
 racy in death certification, chiefly with reference to joint causes 
 or diseases in which malaria is a contributory or complicating cause. 
 
 B. Free Microscopical Examinations 
 
 Public facilities should be provided for the free microscopical exam- 
 ination of the blood for the diagnosis of malaria and the ascertainment 
 of the presence or absence of the malarial parasites, the nature of the pig- 
 ment and leucocytosis, and the numeric relation of the leucocytes, as 
 laid down in the standard text-books on malaria, and the laboratory 
 examination of the blood. 
 
 38 
 
A PLAX FOR ORG AM ZED PREVKXTIOX 
 
 The practical difficulties of blood examinations are the subject of an 
 extended discussion by the Director of the Wellcome Tropical Research 
 Laboratories, Andrew Balfour, M. D., Gordon Memorial College, 
 Khartoum, in the fourth report of that institution, issued in 1911. 
 The general subject of microscopical examination of the blood in malaria 
 is discussed with admirable brevity in the second chapter of Sir Patrick 
 Manson's treatise on "Tropical Diseases," who observes that "For 
 a thorough appreciation of the principles on which t)lood examinations 
 for the demonstration and study of the malaria parasite should be con- 
 ducted, it must be borne in mind that the parasite is intracorpuscular. 
 To see it, therefore, it is necessary, particularly for the beginner, so to 
 dispose of the corpuscles in the preparations that a proportion of them 
 shall lie flat on the slide, in a single layer, and presenting their surfaces, 
 and not their edges, to the observer. It is mainly from ignoring this 
 fundamental principle that so many fail to find the parasite." 
 
 For the same reason it is particularly urgent that the use of the 
 microscope on the part of practising country physicians should become 
 more general, in fact, universal. It has been said in this connection 
 by Deaderick that 
 
 Before attempting the diagnosis of malaria by the microscopic e.xamination 
 of the blood the beginner must become thoroughly familiar with the appearance 
 of normal blood and with the technic of examination, and he should not rely too 
 much upon the result of an examination until he has had considerable experience 
 with malarial blood. 
 
 C. Collection and Preservation of Mosquitoes 
 
 Ix)cal collections of prevailing species of moscjuitoes and their proper 
 preservation, in conformity to the methods of the American Museum 
 of Natural History, are a first essential in the education of school-children 
 and the public as regards the required differentiation of malaria-carrying 
 mo.squitoes and mosquitoes harmless in this respect. 
 
 The collection and i)reservalion of mosquitoes in conformity to exact 
 .scientific re(piirements are, of course, much more difficult than is generally 
 a.ssumed to be the ca.se. It is also far too generally assumed that most 
 of the rec|iiired information concerning the geograpliical distribution of 
 the different species of moscpiitoes is already known and liiat further 
 research i.s, therefore, unnecessary. An excellent illustration of the 
 results of strictly scientifi<- work in this field is a descriptive account of 
 "New Mos(|uil<)es from the Soudan," by Fred \ . Tlieol)al(i, in the Third 
 Ref)ort of the Weilcoriu' Hescanli Laboratory, Kartoum. 1!>0S. A care- 
 fully j)repared guide-book on "How to Collect au<l IVi-scrve Insects" 
 was pul)lished l)y Frank E. Lutz of tli<' .\iiicri( .in Mns<iiin of Natural 
 History, New ^'ork City. 1J)15. .Miention nuiy be directed in this con- 
 nection to "Instructions to Collectors of Sp»'ciriiens for tlie Central 
 Malaria Hureau." drawn up by tin- Connnitte<' for tin* Study of Malaria 
 in India, published in Simla. I!)!';.', "Not«vs on the Mos(|uiloes of the 
 United States." by L. (). How.inl, lulled States ne|>artnuMit of 
 
A PL AX FOR ORG AM ZED PRFA'EXTIOX 
 
 Agriculture, Washington, 1900, and Publication No. VII of the British 
 Museum's Series of Instructions to Collectors of Blood Sucking Insects, 
 London, 1907. 
 
 D. Enforcement of Local Ordinances 
 
 Antimalarial ordinances and their proper enforcement are matters of 
 most serious concern in connection with any and all efforts at malaria 
 eradication. In New Jersey, according to a report of the United 
 States Public Health Service on Communicable Diseases, "The Statf; 
 Agricultural Experiment Station is required by law to make, at the; 
 request of local authorities, an investigation into the causes responsible 
 for the existence of mosquitoes in any locality and suggest measures to 
 abolish them. The local health authorities must be informed of the 
 findings and they in turn are required to notify property owners of their 
 duty to remedy the conditions responsible for the breeding of mos- 
 quitoes, and should the owners fail to do this, the local authorities may 
 take the necessary measures, the cost to become a lien on the prop- 
 erty." Provision is made in New Jersey for state and municipal 
 cooperation and the appointment in each county of mosquito extermina- 
 tion commissions, the amount of money necessary for the discharge of 
 their duties being included annually in the tax levy. Much valuable 
 additional information concerning law and legislation with reference to 
 insects capable of transmitting disease is contained in the report referred 
 to, as well as in supplementary publications on municipal ordinances, 
 rules and regulations pertaining to public health adopted by cities of the 
 United States having a population of over 10,000 in 1910. A typical 
 ordinance in this connection is the following, adopted by the city of 
 Chattanooga, Tenn., under date of March 10, 1913: 
 
 Be it ordained by the board of commissioners of the eitj- of Chattanooga, Tenn. , 
 That it shall be unla^\■ful for any owner, tenant, or agent, in control of any lo t 
 or premises ^\-ithin the corporate Hmits to permit to remain thereon any emptj ' 
 bottles, empty cans, or other receptacles likely to gather and hold water. Anc I 
 any such owner, tenant, or agent, failing to remove all such articles from his lot' 
 or premises ■nithin five days after notice from the department of health to do so, 
 shall be guiltj' of a misdemeanor, and upon conviction shall be punished bj' a 
 fine of not less than $2 nor more than SIO for each offense. 
 
 The full text of the New Jersey law with reference to the prevention 
 of the breeding of mosquitoes, adopted under date of May 21, 1912, is 
 republished in the report on state laws and regulations pertaining to 
 public health issued by the United States Public Health Service as 
 reprint No. 200, Washington, 1915. 
 
 E. State Drainage Commissions 
 
 Active efforts are required in behalf of the establishment of State 
 Drainage Commissions and drainage districts for the earliest possible 
 elimination or reduction of overflowed areas or swamp-lands which under 
 existing conditions are useless for agricultural purposes and a serious 
 menace to health and life. 
 
 40 
 
A PLAN FOR ORG AX I ZED PRFJ'KXTIOX 
 
 The principles of engineering for land-drainage and the reclamation of 
 water-injured lands have during recent years been worked out with 
 remarkable thoroughness. Tidal marshes and their reclamation have 
 been reported upon by Mr. George M. Warren, Drainage Engineer of the 
 United States Department of Agriculture, and the same office has issued a 
 suggestive report on "Drainage by Means of Pumps," by S. M. Wood- 
 ward, Drainage Engineer. A very useful manual on "Drainage and 
 Reclamation of Overflowed Lands" has been issued by the Bureau of 
 Legislative Information of the State of Indiana, and the general subject 
 of the "Drainage of Farm Lands," has been reported upon by C. G. Elliott, 
 Drainage Expert of the United States Department of Agriculture. The 
 general principles of the establishment of a drainage fund are set forth 
 in a report submitted by Mr. Flint, of the Committee on Pul)lic 
 Lands, and i.ssued as a Senate Document (Report No. 734'2, 59th Con- 
 gress, 2d Session, 1907). The general subject of drainage has received 
 occasional, but far from sufficient, consideration by the Atlantic 
 Deeper Waterways Association and the National Rivers and Harbors 
 Congress. Perhaps the most important practical work in this direction 
 has been done in the state of Arkansas, as set forth in a Report on the St. 
 Francis Valley Drainage Project in Northeastern Arkansas; but special 
 mention requires to l)e made of the truly astonishing results which have 
 been achieved under the drainage district laws of the state of North 
 Carolina. A general statement on Swamp and Overflowed Lands in the 
 United States, with reference to ownership and reclamation, l)y J. O. 
 Wright, Supervising Drainage Engineer, has been issued by the 
 Dej)artment of Agriculture. Washington 1907 * 
 F. Schools for Tropical Medicine 
 
 More adequate support is required for American Schools of Tropical 
 Medicine, for the pur{)()sc of j)roviding ways and means for thoroughly 
 s{)eciali/.ed scientific iuxcstigatioiis of the geographical distril)ution 
 of malaria throughout the western hemisphere and of the achievements 
 and possibilities of malaria eradication in the countries of Latin America 
 in which the disease is known to j)ie\ail to a more or less considerable 
 degree. Increased support is also needed for the more scientific study 
 of blackwater fever and an}' and all alli<'(l tro|)ical diseases increased in 
 frequency or severity on account of being complicated by malaria, t 
 
 Ci. Non-("ontij{uou.s I'osscssion.s of the I'nited .Stattvs 
 'i he active cooperation of the National ( 'oniiniltee with the authorities 
 of the non-contignoiis possessions the United States represents an 
 
 •S<-f Kiillrtin No. MH, "DrjiiniiK'* !<»»' <>f llx" Slulc of South <'iirolinii," of the Sinic Drpnrlinriit of Aifri 
 nillurc, ('oniiDprc-c niiil liidii^ilric.i, ('oliiinl)iii, 11114. .Mho. tlir I'riM'ccilinK'i of thr llliiioii Aiiniinl l>riiiiin»(i- 
 ('oiif<Ti-ii<r, iiikIit Ihr (lin-rtioii of Ihr Colli'Hr of Knt{iiii-<'riiiK. I'nivcTsil.v <.f Illinois, (rliiiiiii. lllitioi>. 
 
 tOf viiliK- ii<i ronvc-iiiiMil tiMirrr* of Iriiil worlliy iiifor unit ion iin- 1 In- itiiniial r<-|>orl:t of tlir .\i|vi«)r.v Coniiiiittrr 
 of till' Tropiriil I >i!«'ii!ir.« l(('<iiMir>'li h'liinl, iiiilili.tlii-il ihimiiiiII.v liy onlrr of I'lirlliiiiK'nt uiiil roiitniiiiiiK <'x(<'ndr<J 
 iii'i'oiintii of iiiitiiiiiiliiriiil iiiriiHiirr<i iiml ri"iult» lliroiiKlioiit tin- llriliuli CroMii ('olonir<i nnil I'rotrotorktri. 
 Thrsr ri'iHirtx iiri- iiii luliiiinilili' •'Xuiii|ilc of llir form in wliiili IimiiI uoviTiiiiiiMitH hIioiiM aiiiiiiBlly prnrnt thr 
 fnct.i of lornl frr(|iictii'y of iniiliiriiil ili.triiitr* nml llii- prrviiiliiiK or roiiti'iiipliitril niitiiiinluriiil mpa<um for thr 
 iiiorr rffcitivr ronlrol or piooililr rrjiiliriitioii of thr <li«fii«f. 
 
 II 
 
A PLAN FOR ORGANIZED PREVENTION 
 
 important problem. In tlie furtherance of the cooperative effort for tht M 
 gradual eradication and more effective control of malarial diseases, it 
 is particularly desirable that the local incidence of the disease in our 
 island possessions should be made the subject of a thorough and strictly 
 scientific inquiry. The malaria problem in our tropical possessions 
 should be considered with the same degree of thoroughness and complete 
 ness as has, for illustration, been the case in the investigation into the 
 causes of malaria in Bombay. The service of United States Marines in 
 certain portions of Haiti, San Domingo, Cuba and Nicaragua need only 
 be referred to as a further practical illustration of our increasing interest 
 in the health conditions of the western hemisphere. 
 
 H. Meteorological 
 
 The more scientific study of the correlation phenomena of malaria 
 occurrence and meteorological conditions is of particular urgency, as 
 best illustrated by the recent contributions of O'Connell on Meteorology 
 and Malaria to the Journal of Tropical Medicine and Hygiene. Instru- 
 mental observations require to be made with more accuracy and mi- 
 nuteness, and the statistical analysis of the data should be in much more 
 detail than has heretofore been the case.* 
 
 I. Statistical Considerations 
 
 The statistical analysis of malaria mortality and morbidity data, as 
 well as the correlation of malaria with other diseases, has not heretofore 
 been made with the required degree of thoroughness and attention to 
 detail. As an excellent illustration of the method more or less to be 
 followed, reference may be made to the statistical analysis of data 
 relating to an epidemic of plague in three districts of the Punjab by M. 
 Greenwood, Jr., Statistician to the Lister Institute of Preventive Medi- 
 cine, also to the report by S. R. Christophers, contributed to the Trans- 
 actions of the Committee for the Study of Malaria in India, on "Epi- 
 demic Malaria of the Punjab, with a Note on a Method of Predicting 
 Epidemic Years." Accurate and conclusive statistics and qualified 
 methods of analysis are of such exceptional importance in malaria in- 
 vestigations that it can not be too strongly urged that this aspect of 
 the problem of the gradual and ultimate eradication of malaria should 
 receive the most thoroughgoing consideration, including a reexamina- 
 tion of the statistical material at present available regarding the geo- 
 graphical distribution of malarial diseases and the variation of incidence 
 according to age, sex, race, occupation, etc. 
 
 The Report of an Investigation into the Causes of Malaria in Bombay 
 and the Measurements Necessary for Its Control, by Chas. A. Bentley, 
 
 *The most recent contribution by Dr. O'Connell on Meteorology and Malaria, with special reference to 
 malarial fevers, in England appears in the Journal nf Tropical Medicine and Hygiene for December 15, 1916, 
 in which the atmospheric conditions of Greenwich in August, \iiiS, are subjected to a minute analysis, since at 
 this time malarial fevers were quite common in the southeast of England, which fact, by Dr. O'Connell, is at- 
 tributed to the atmospheric conditions, which "were such as would cause pyrexia for a certain number of 
 hours bn ten different days." (For more extended observations on meteorology, see pp. 14-16.) 
 
 42 
 
 ;tc 
 
A PLAN FOR ORGANIZED PREVEMIOX 
 
 d. D., Bombay, 1911, is one of the most important contributions to 
 he practical question of malaria eradication and control. The report 
 acludes extended observations on the methods of measurements of 
 nalaria in Bombay by means of the spleen index, blood examination, 
 nd analysis of the mortality returns, following a thoroughly scientific 
 iscussion of the mosquitoes of Bombay. The conditions which in- 
 uence mortality are presented in a brief survey, with reference, first, 
 the anophehne factor and, second, to the human factor. Reference 
 i also made to overcrowding, soil disturbance, migration, education, 
 tc. The prevention of malaria in Bombay is considered with reference 
 o the history of past efforts, the legal aspects of mosquito prevention, 
 he cost of mosquito prevention in different malarial localities through- 
 ut the world and finally the cost of permanent measures. Following 
 hese observations are sections on the obstacles to malaria prevention, 
 he place of quinine in malaria eradication, and special reasons which 
 lake it imperative "that malaria should be eradicated from Bombay." 
 'he report is illustrated by a number of instructive maps, diagrams, 
 lates and appendices of climatological and mortality data. No local 
 rea in the United States has been investigated and reported upon 
 atli a similar degree of thoroughness and scientific as well as practical 
 onclusiveness. 
 
 J. Quinine Prophylaxis 
 
 On account of the highly specialized nature of the quinine question in 
 s relation to malaria eradication and control, it seems advisable that this 
 latter should be subjected to a thorough reconsideration, with special 
 sference to the experience which has been had during the construction 
 eriod of the PanamaCanal. Of special value, also, is the practical cxperi- 
 nce in quinine prophylaxis in the island of Jamaica, aside, of course, 
 -om the well-known methods and results secured in Italy and in certain 
 actions of India, particularly Bombay. 
 
 The controversial aspects of (luinino pro])hylaxis suggest a thor- 
 ughly impartial reconsideration of all the available facts. According 
 
 Dr. Angus McDonald, in an address before the Society of Tropical 
 ledicine and Hygiene, "(^iiiuine has its position in relief and cure, but 
 
 1 sanitary administration it has none." This rather far-reaching coii- 
 lusion is amplified in the statement that "continuous drugging with 
 uinine may prevent attacks of malaria in anopheline countries, but 
 tatislics are still lacking to (jemonstrate the extent to which the taking 
 f this drug pn^vents infection. That the Iminaii iiidividiia! is dctri- 
 lentally affected by the continued absorption of (luinine. I)e lie atfccted 
 vith malaria or not, there can l)c little doubt. Whatever arc the causes 
 r blackwater fever, there seems to be a (consensus of opinion that 
 niriiiic has iiuicli to do with it, p(>rhaps more to «lo with it than malaria 
 ;i-." This conclusion wjus ojjposed by Dr. ('. K. Hartford, who. with 
 IM'cial reference to Kuropean missionaries in ('entral, Ka.st and \Nest 
 Vfrica, points out "that there is good cause for adv(x-uting the u.sc of a 
 
 43 
 
A PLAN FOR ORGAMZED PREVEXTfOX 
 
 daily dose of quinine of five grains, which has in the past produced mos 
 important results." The effect of quinine on the malarial parasite 
 both in mosquito and in man, has been reported upon with admirabl 
 scientific thoroughness by Dr. Samuel T. Darling, formerly Chief of th 
 Laboratory of the Board of Health of the Panama Canal Zone, in hi 
 "Studies in Relation to Malaria." 
 
 Of interest in this connection is the following extract from the repor 
 on "Sanitation in Bengal for the Year 1914," published in Calcutta 
 1915: "It is gratifying to observe that the efforts of the Malari; 
 Committee to popularize quinine appear to be meeting with success 
 and there was considerable demand for quinine in the 'treatment' forn 
 in which it is now sold. The sale of quinine in this form has nearl} 
 doubled since August, 1913. Quinine was distributed free to school 
 children in the Hooghly district through the agency of the Educatior 
 Department, and some District Boards spent considerable sums in th( ^r' 
 purchase of cjuinine for free distribution. . . . The first ste] \'o 
 towards the elimination of malaria is the extension of the use of quinine 
 both as a prophylactic and as a curative medicine. Much good will nc 
 doubt result from measures for the improvement of drainage and culti- 
 vation, but these by themselves will not prevent the spread of malaria."* 
 
 .on 
 
 ie 
 
 K. Institutional Treatment of Malaria 
 On account of the fact that malaria is so largely a rural disease, it would 
 seem of sufficient importance to undertake an inquiry into the rural 
 hospital facilities for proper institutional treatment, as opposed to super- 
 ficial and inadequate treatment at the patient's home. Since malaria is 
 widely spread through carriers suffering from latent malaria, it is 
 of the first importance that as far as practicable every malaria 
 patient should be thoroughly cured of the disease, to the extent, at 
 least, of no malarial parasites being ascertainable in the peripheral cir- 
 culation. Since the guarding of malaria patients against reinfection is 
 of sufficient importance as a public-health precaution, the institutional 
 treatment of malaria suggests itself as decidedly more effective than 
 treatment at the patient's home. Attention may be directed to the 
 excellent sanitary results which have been obtained by means of adequate 
 rural hospital facilities for plantation laborers in Hawaii and in con- 
 nection with the plantations, etc., of the United Fruit Company, in 
 Cuba, Guatemala, Costa Rica, Colombia, etc. f 
 
 *Some exceptionally useful observations on Quinine Propaganda in Bengal, by C A. Bentley, and the 
 Quininisation of School Children in the United Provinces, by Maj. F. D. Graham, are contained in the Pro- 
 ceedings of the Third Meeting of the General Malaria Committee held at Madras, in 1912. See, also, in this 
 connection Chapter iv on the Treatment of Malarial Fevers, with special reference to the use of quinine in 
 Malarial Fevers, by Chas. F. Craig, M. U., New York, 1909., and Chapter viii on Treatment of Malaria, in 
 Deaderick and Thompson's "Endemic Diseases of the Southern States," Philadelphia, 1916. 
 
 tThe excellent results of adequate hospital facilities are described by Malcolm Watson in his treatise on 
 "Rural Sanitation in the Tropics," with special reference to the plantation system of the Dutch Tobacco 
 Company, of the island of Sumatra. Between 1901 and 1911 the general hospital death rate was reduced from 
 11.4 per cent, to 2.6 per cent., and the general death rate of the entire labor force from 50.0 to 12.0 per 1,000. 
 The principal hospital is located at Medan and contains about 600 beds. During 1910-1911 the admission 
 rate for malaria was only 2.4 per cent. 
 
 44 
 
 II 
 
A PLAX FOR ORGAMZKD FRFA'EXTIOX 
 
 '^ L. Historical Research 
 
 The appearance and disappearance of malaria in different sections of 
 
 ''< 16 world during more or less prolonged periods of time have an important 
 
 'earing upon the better understanding of the conditions and circum- 
 
 'ances which govern the control and ultimate eradication of malarial 
 
 isease in the western hemisphere. The early history of malaria in Greece 
 
 '^ nd Italy and its relation to the social and economic progress of the pop- 
 
 lations concerned and its possible causative influence on the decay of 
 
 ^ ertain nations of antiquity forcibly suggest the value of pertinent his- 
 
 orical illustrations in support of modern efforts to eradicate malaria 
 
 om vast portions of the western hemisphere which are at present 
 
 ither more or less uninhabitable on account of malarial disease or which 
 
 ave been materially hindered in their economic progress, as best illus- 
 
 rated by the Yazoo Delta of Mississippi, a large portion of the states of 
 
 "^irkansas and Louisiana and contiguous areas in the coastal plain of 
 
 North and South Carolina and Georgia.* 
 
 M. Zoological 
 
 The practical use of natural enemies of mosquitoes suggests a vast 
 eld of qualified scientific research of a high order of importance. The 
 ooperation of the United States Fish Commission might be enlisted in 
 n effort to ascertain how far certain fishes have been found useful in the 
 Vest Indies and Hawaii in local efforts at mosquito eradication, and 
 vhether such methods of eradication might advantageously be intro- 
 luced into the United States. Much the same conclusion applies to a 
 urther inquiry into the efficiency and practical usefulness of alleged 
 leterrent trees and plants, such as the eucalyi)tus, the papia, the china- 
 )erry trees, water-plants, etc. The United States Department of Agri- 
 ulture, through its numerous scientific subdivisions, in cooj)eration with 
 he Natif)nal Museum and the American Museum of Natural History, 
 IS well as other organized scientific bodies, should be in a position to 
 cndcr substantial aid in this direction.! 
 
 'The most useful source o( information on the early histor>' of maluriul disenses is llie "HaniUmok of Gro- 
 
 raphirnl and Historical PathoioK.v," by Ur. AuKust Hirsch, translated t>y Charles C'reif{hton. lAjndon, 189S. 
 InlereslinR historical data and early slalisliis are iiiclii<|ed in the treatise on Malaria liy Prof. Dr. Angelo 
 
 'elli, <d (ierinan Ed., Berlin, IIM.S. A curious and practically unknown coiilrilmtion to the early hi.story of 
 tialaria is a work entitled "Dello Stato Kisico del Suolo de Kouia. Meinoria per servile d'illuslrazione alia 
 
 'arta (leognostica di quritn cilta. Di. (i. Hro<chi. Konin, 1H<0, reviewed in the Edinburgh R*riev, Frbruary, 
 
 SH. Also, "Travels of Intermittent Fever," in Khode Islan<t Annual Health Heport, IHH6. 
 
 tin an admirable address on "Insect Home Diseases in l'an-.\merica," by Dr. Juan (iuiteras. Director of 
 
 leallh of Cuba, and professor of K<°i<cral pathology ami tropical diseases in the Cniversity of Havana, read 
 lefore the Second Pan-.Vmeriian Scienlilii' ConKress, an extended ri-ferencc is made to the early otiservalionsof 
 
 >r. Josiah C. Nutt, of Mobile, .Ma., on yellow fever, aa contrasted with bilious fever, and rea.sons for believiiiK 
 t a disease lui generis, its mode of propagation, remote cause, probable insect or animalcular origin, etc., which 
 ippeared in the .V'eir OrUana Medtcul and Surgical Journal for March, IH'iH. This paper for the lirst time 
 irescnied the insect hypothesis in ilisease transmissiim, w liich has .since heconie universnllv accepted ou the 
 lasis of the subse<|uent precise ascertainment of the true cause of yellow fever by the I nited States .\rniy 
 Vfedical Hoard, consistiug of Drs. Heed, Luxear, (,'arroll and .VKramonte, who, however, in a large measure 
 iwe the results of their immortal discovery to the previous researches of Dr. Carlos J. Finlay, of Havana, who 
 
 ince IHHI had been investigating and reporting upon the possible relation of the mosi|uilo to yellow fever, and 
 if Dr. H. It. Carter, of the L'nileil Slates Public Health Service, who, some years earlier, had made public bis 
 
 poi'h-making observations upon the intrinsic incubation of > ellow fever. As well said by Major-deneral 
 'iorgas. in his work on Sanitation in Panama. "The report of Carter turned out to be pure gold ami was one of 
 
 \5 
 
A PLAN FOR ORGANIZED PREVENTION 
 
 The practical use of natural enemies of mosquitoes is discussed at 
 some length in Volume I of the treatise on "The Mosquitoes of North 
 and Central Ameriea and the West Indies," by Howard, Dyar and Knab, 
 published by the Carnegie Institution in lOlS. A reference of special 
 interest is to the introduction of the so-called "millions," which are a 
 minnow of very small size (the full-grown females measuring only about 
 one and one-half inches in length, while the male is much smaller), from 
 the island of Barbados, which is free from malaria, into the more or less 
 permanent waters of the island of Antigua, which is considerably afHicted 
 with the disease. It is said that many planters and others commented 
 on the evident abatement of the mosquito nuisance in numerous localities. 
 A limited test in the Panama Canal Zone was apparently productive of 
 satisfactory results, for Major-General Gorgas is quoted in a statement 
 to the effect that he approved of the use of "millions" wherever it could 
 be done. Malcolm Watson, in his treatise on "Rural Sanitation in the 
 Tropics," reporting upon conditions in Barbados, contradicts the general 
 theory that the absence of malaria from the island was attributable to the 
 universal presence of "millions," holding that Barbados is free from 
 malaria "because of the relative absence of breeding-places," due to the 
 exceedingly favorable conditions of natural subsoil drainage. In the 
 treatise on "The ^Mosquitoes of North and Central America and the 
 West Indies," by Howard, Dyar and Knab, extended consideration is 
 also given to alleged deterrent trees and plants, chiefly the eucalyptus, 
 ricinus and papaya, china-berry trees, peat and water-plants. The 
 whole question of natural enemies is admirably summarized by Mr. 
 John B. Smith, Entomologist of the New Jersey State Agricultural Ex- 
 periment Station, in his report upon the mosquitoes occurring within 
 that state, their habits, life history, etc. 
 
 XIV. General Conclusions and Observations on the Economic 
 Importance of Malarial Diseases 
 
 The economic losses resulting from malaria are enormous, but exceed- 
 ingly difficult of precise ascertainment. In 1903 Prof. Glen W. Herrick 
 contributed an article to the Popular Science Monthly on The Relation 
 of Malaria to Agricultural and Other Industries in the South, which in 
 1909 was followed by a bulletin of the Bureau of Entomology on The 
 Economic Loss to the People of the United States Through Insects 
 That Carry Disease, by L. O. Howard. The same distinguished author- 
 ity gave more extended consideration to the subject in the first volume 
 of the collective investigation on "The Mosquitoes of North and Central 
 America and the West Indies," published by the Carnegie Institution in 
 
 the great steps in establishing the true method of transmission of yellow fever." The sanitary achievements in 
 Havana, past and present, arc primarily the work of Major-Ooncral W. C. Gorgas and Dr. .luan Guileras. It 
 is entirely due, however, to the cnli^chtened attitude of the Cuban government that the theories of insect-borne 
 diseases have been rigidly applied and that both yellow fever and malaria have become practically extinct in 
 an island which, in former years, was often disastrously afflicted by both of these diseases. Reference may 
 also be made here to an interesting contribution on the mosquitoes of the Republic of Cuba, by Dr. J. H. 
 Pazos, of Havana. 
 
 46 
 
A PLAN FOR ORGANIZED PREVENTION 
 
 1912. Prof. Howard at the time estimated the malaria death rate for the 
 entire United States at 15 per 100,000 of population, equivalent to an 
 annual loss of life of 12,000. He points out that this is but an inadequate 
 indication of the economic loss in health and physical strength, for "A 
 man may suffer from malaria throughout the greater part of his life and 
 his productive capacity may be reduced from fifty to seventy-five per 
 cent, and yet ultimately he may die from some entirely different im- 
 mediate cause." Assuming, however, a mortality of 12,000 per annum, 
 Prof. Howard estimates the number of cases of malaria at 1,500,000, of 
 which it is safe to assume the larger proportion occur in adult life. 
 
 More recent discussions of the economic aspects of malaria, with 
 special reference to agriculture, are by W. D. Hunter and D. L. Van 
 Dine, of the United States Bureau of Entomology, concluding with 
 a paper on the Relation of Malaria to Crop Production, by D. L. Van 
 Dine, published in the Scientific Monthly, November, 1916. It is stated 
 that Howard in 1909 estimated the annual economic loss on account of 
 malaria throughout the United States at not less than $100,000,000, 
 and subsequent investigations, including a careful analysis of actual 
 plantation-labor experience, indicate that this estimate is probably con- 
 servative. William B. Hermes, in his treatise on malaria, with special 
 reference to California, has estimated the economic loss on account of 
 malaria in that state at nearly $3,000,000. The same authority quotes 
 the opinion of the National Conservation Commission that eighty per 
 cent, of the malaria in this country could be prevented. Dr. Graham A. 
 Henson, in his work on malaria, published in 1913, observes with reference 
 to the economic loss that on the basis of such data as were available and 
 the knowledge" of what has been accomplished wherever a consistent cam- 
 paign has been instituted against malaria infection it would appear that 
 the time can not be far distant when the importance of the eradication 
 of the disease will be taken up seriously by legislative and administra- 
 tive bodies." This conclusion applies to every country in which malaria 
 is known to prevail to a more or less serious degree; but to no section 
 of the world as much as to the Southern States and the malarious regions 
 of the Central and South American Republics. A material reduction 
 in the malaria death rate can not fail to bring about a lesser prevalence 
 of other serious diseases, for wherever malaria prevails extensively the 
 general death rate is high, even though the disease itself may not be a 
 predominant cause. The average death rate, for illustration, of Mauritius, 
 which is intensely malarious, during the three years ending with 1906 
 was 37.6 per 1,000 of po[)ulation, whereas the corresponding average 
 rate for the nearby Seychelles Islands was only 15.9. The Seychelles 
 are mountainous and practically free from anopheles mosquitoes. 
 
 The malaria death rate is not, of course, a sufficient basis for an 
 estimate of the economic loss resulting largely in c()nse((Uonce of pro- 
 longed illness and diminished physical ofHciency. The economic value of 
 human life also varies considerably according to age, race and local labor 
 
 47 
 
A PLAX FOR ORGANIZED PREVENTIOX 
 
 conditions, so much so that practically any and every estimate is largely 
 a matter of pure conjecture. Estimating the present malaria mortality 
 of the United States (for 1916) on the basis of revised data brought down 
 to date for the Southern registration states and cities at 15, 000 deaths 
 and assuming a fatality rate of 1.5 per cent., the approximate number 
 of cases of malaria in this country per annum can not fall below 1,000,000. 
 Possibly the actual number is materially in excess of this assumption. 
 The cause of malaria eradication, therefore, rests upon sound economic 
 as well as self-evident humane considerations, leaving no escape from 
 the final conclusion that the entire subject most urgently demands the 
 qualified and intelligent coordination of all existing governmental 
 agencies and related health-conserving activities, on the one hand, and 
 a broad-minded public policy, on the other, with special reference, 
 however, to expenditures in behalf of local antimalarial measures on 
 the part of the general public. For economic reasons alone the 
 effort would be worth while, since the economic results of effective 
 antimalarial measures are a foregone conclusion. The attainment of 
 more or less complete malaria eradication throughout the country will 
 require many years of intelligent, coordinated effort, sustained by 
 liberal governmental appropriations, than which no nation in the 
 world could make a better investment for the good of its citizenship 
 than the United States. The fundamental principle of permanent 
 success in malaria eradication is the intelligent and effective coordi- 
 nation of all the measures and means, agencies and organizations, that 
 can be utilized in the warfare against this most insidious foe of mankind. 
 A perfect working plan, however, can only be the result of extended 
 experience and mature consideration on the part of many men and minds 
 thoroughly familiar with the facts and conditions of local experience 
 resulting either in failure or success. It is hoped, therefore, that the fore- 
 going considerations and suggestions may prove of practical value in the 
 ultimate attainment of our national ideal of the most perfect health and 
 the longest attainable duration of life throughout the entire United States, 
 w^hich is far from being the case at the present time. As has well 
 been said by the late William Edward Hartpole Lecky, "How different 
 would have been the condition of the world, and how far greater would 
 have been the popularity of strong monarchy if at the time when such 
 a form of government generally prevailed rulers had had the intelligence 
 to put before them the improvement of the health and the prolongation 
 of the lives of their subjects as the main object of their policy rather 
 than military glory or the acquisition of territory or mere ostentatious 
 and selfish display!" This observation holds even more true for a 
 republic, in which responsibility for governmental policy rests primarily 
 upon the people themselves. In its final analysis, therefore, the prob- 
 lem of malaria eradication is one of public education and an aroused 
 public conscience and understanding regarding the largely unnecessary 
 loss of life and health in consequence of the continued and unnecessary 
 
 48 
 
A FLAX FOR ORdAMZKn riHAIXIKKX 
 
 prevalence of malarial diseases. In proportion a.s the piil)lic knowledge 
 of the measures and means whereby malaria can l>e eradicated is j)er- 
 fected will the elimination of this disease from, at least, the Iniled States 
 be attained within a measurable period of time.* 
 
 •Annoni? the sueeestive recent indications of an aroused interest in ni .' - ...o 
 
 to the Journal of Tropical Medicine and Hyjiene, by Or. W. M. Mcli -1. 
 
 .lohn, .\nlipua, recommendinK the institution of rural anti-ni»s<|uitu ni' li, 
 
 1916). Dr. McDonald suggests the estatjiishment of an ex[>erimental aria fu- • <4 
 
 the efficacy of various anti-mosquito measures on the hiisic primiple of (iovrrnin Ird 
 
 as bearing the same relation to the prevention of dis<-a»i- among Ulwrrri a« ;:. \. !al 
 
 Station does to the prevention of disease among cane*. The prinnpal obj<-<ls of i . %n 
 
 explained to be "(a) to provide practical knowledge of the working of vfiriiiii« -inti-i-; to 
 
 dclcrniine which of these measures in practice combine a maximurj. to 
 
 determine whether the cost of the more exp»-n.sive measures it, in r . ; Itjr 
 
 the results of these measures; (d) to determine whether adoption "' . .• ta 
 
 prove of any avail even if we are deterred b.v financial limitations frum uarryiag out Lbc au>rv cspEoairr oir**- 
 ures." 
 
 The several more important rural antimalarial measures arc slat>-il in '" ■ • ' . «« 
 
 follows: "(1) Utilizittion of the natural enemies of the nios<|uiti>, such .i» 
 
 fb) Oiling of pools, ditches, and stream*, (r) Drainage. i<i) (iratiing i r.xtA. 
 
 otherwise be effectually treated." 
 
 The article concludes with the statement that "the relative cost of HHcienc)* ol tbear mrmaurra raa oaljr 
 be ascertained by practical experimental work io the field, but in view of the l)enefitj w'- '■ - ' ' --- i- ■ > tb« 
 individual, to the landowners, to the (iovernment, and to the community generally b-. .rn 
 
 the reduction of malarial and filarial disease in the colony, 1 would miMt rrs[>ct-lftillv • .Ii.- 
 
 money could not be better spent than in the establishment of an ex|xTi ■ <rf 
 
 antimalarial measures having in view the eventual institution of an a'. il»«- 
 
 island. I venture to represent further that the present moment, when th<- , _ . . ._ 'er* 
 
 has been attracted to the economic value of erailication of liisease by the work done in the .Vnkylastooiiaaa 
 Campaign, is an opportune time for enlisting the cooperation of the public in antimalarial work." 
 
 Of special practical educational value are the illustrated placards iHued by the Philippinr llrallh Srnri«» 
 ill the native languages, showing the life history of the mosquito and the method of Irantmiuion of malarial 
 infection, used in the biirrio-i of .Mindoro. 
 
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PART III 
 
 SOME ESSENTIAL STATISTICAL CONSIDERATIONS 
 
 An effective and far-reaching practical plan of malaria eradication 
 must obviously rest upon a well-considered statistical basis of evidence 
 derived from trustworthy official and other sources. The selection of 
 unit areas for active antimalarial measures is in its initial considerations 
 largely a statistical problem, and the results of subsequent experience, 
 or the efficiency or failure of particular methods and means, are often 
 determinable by statistical methods alone. Many important aspects of 
 the problem of malaria prophylaxis require the ascertainment of ele- 
 mentary conditions in conformity to qualified methods of statistical and 
 even mathematical analysis. The best illustration of this point of view 
 is the elaborate presentation of evidence on the prevention of malaria 
 in the collective treatise on the subject by Sir Ronald Ross, which includes 
 contributions by Prof. L. O. Howard, Major-General W. C. Gorgas, 
 J, A. LePrince, Prof. A. Celli, etc. International statistics of malaria 
 frequency are, unfortunately, not thoroughly trustworthy, although in a 
 general way they may be relied upon as approximately conclusive. 
 Since malaria is largely a disease of rural sections, it is really deplor- 
 able that the larger portion of the rural area of the Southern States 
 in which the disease is known to prevail to a more or less serious degree 
 should not be wnthin the registration area as defined and accepted by the 
 Division of Vital Statistics of the United States Census. 
 
 In view of the fact that the mortality from malaria is not a true index 
 of the relative seriousness of malaria frequency as a disease, it is even 
 more regrettable that malaria morbidity data for many important 
 infected areas should not be obtainable otherwise than by means 
 of institutional returns, which, of course, may or may not be con- 
 clusive. Since the fatality rate in malaria varies considerably ac- 
 cording to the type or form of malarial infection, it is self-evident 
 that the extent of morbidity is not always safely ascertainable, with 
 even approximate accuracy, from mortality returns which fail to differ- 
 entiate the principal types of malaria, i)articularly tiie tertian, the 
 estivoautumnal and the quartan infection. In some sections one type 
 prevails, to the ])ractical exclusion of the others, with a high morbidity 
 and a low mortality rate, while in others the morbidity rate may be less, 
 but the mortality rate much higher. For the United States registration 
 area during the period 1010-1914 the average mortality from malaria was 
 2.6 per 100,000 of population, which in proportion to the mortality from 
 other causes is obviously insignificant. The returns for the United 
 
 51 
 
STATISTICAL CONSIDERATIONS 
 
 States registration area, unfortunately, are exclusive of the sections 
 of the Southern States where the disease is known to prevail to a 
 more or less serious degree. Thus, for illustration, when the returns 
 for the state of Kentucky and the registration cities of Tennessee and 
 Alabama are combined, the resulting average malaria mortality rate is 15.0 
 per 100,000 of population. For the cities of Tennessee alone, however, 
 the rate is 40.2. No general malaria mortality returns for states and 
 large areas can, therefore, be considered conclusive, and in all cases a cor- 
 rection is necessary for the possible impairment of the data on account 
 of the inclusion of institutional returns. Malaria is nearly always a local 
 'problem, and the rate of incidence is governed by local conditions. Even 
 in the Pacific Coast States, where the disease is relatively rare and, 
 as a general rule, not of serious importance, particular localities may 
 be and are subject to a comparatively high rate of incidence of malarial 
 infection, which is obscured in the low general average mortality or mor- 
 bidity for the state at large. In North Carolina, including only munici- 
 palities with at least 1,000 population, the malaria mortality rate is 26 
 per 100,000 of population; in the city of Charleston, S. C, during the 
 period 1910-1914, it was 30.9; in the principal cities of Georgia, 27.6; 
 and in the principal cities of Florida, 27.7. These rates are fairly 
 conclusive, but the populations directly concerned suffer to a much 
 larger extent than is indicated by average returns.* 
 
 Probably the most intensely malarial sections of the United States are 
 the Yazoo Delta counties of Mississippi, the river counties of Tennessee, 
 the river counties of southeastern Missouri and the river counties of 
 Arkansas and northern Louisiana. It is only, however, for the river 
 counties of southeastern Missouri that approximately trustworthy data 
 are available, and these indicate an extraordinary degree of malarial in- 
 tensity. Combining the returns for seven counties of Missouri, it ap- 
 pears that the average rate of mortality from malaria for the four years 
 ending with 1914 was 168.8 per 100,000 of population and that the rate 
 was as high as 296.7 for Dunklin County, which as far as known is 
 probably one of the most intensely malarial sections as regards the fatal 
 form of malarial fever in this country. Possibly certain counties of 
 Arkansas and Mississippi, however, are even more seriously affected, but 
 no official mortality returns regarding them are at present available. 
 It is quite probable that the local intensity may be decidedly 
 higher, but thus far, excepting to the extent of the active efforts on 
 
 *Some exceptionally valuable local investigations have been made by the United States Public Health 
 Service in the direction of ascertaining the precise degree of intensity in the geographical area. Among other 
 publications of practical value reference may be made to reprint No. 160, Malarial Fevers in Arkansas; reprint 
 No. m. Malarial Fevers in South Carolina, Georgia and Florida; reprint No. 186, Malarial Fevers in Ala- 
 bama; and reprint No. 193, Malarial Fevers in Mississippi. Reprint No. 277 has a general review of malaria 
 morbidity by states and types of infection, with a due regard to race by counties and seasons of the year. 
 This investigation, limited to eight Southern states, includes 81,085 cases of malaria reported, but only on the 
 basis of 13 per cent, of returned replies to the cards mailed to practising physicians in the states referred to. 
 The approximate morbidity rate, as estimated by this investigation, made chiefly under the direction of the 
 late R. H. von Ezdorf, was 5.36 per 1,000. If calculated on the basis of complete returns, the true malaria 
 morbidity rate in the eight states combined would be 4 per cent., equivalent to 600,000 affected persons for 
 the year. 
 
 52 
 
S TA TIS TICAL CONSIDER A TIOXS 
 
 the part of the International Health Commission of the Rockefeller 
 Foundation, a thoroughly qualified investigation has not been made. 
 The practical importance of malaria frequency and the urgency of its 
 eradication in southeastern Missouri are best illustrated by the fact 
 that the rate for Dunklin County of 296.7 per 100,000 is in excess of the 
 corresponding rate for Trinidad and Tobago of 218.9; and almost the 
 same as the rate for Venezuela, which is .'50.3. (J. Even the city of Free- 
 town, Sierra Leone, on the West Coast of Africa, with its notoriously 
 high general death rate, has a malaria rate of only 251.8, in contrast to a 
 rate of 296.7 for Dunklin County. Granting that the true intensity of 
 malaria frequency can not be accurately determined by means of the 
 death rate as ascertainable uj)on the basis of more or less untrustworthy 
 death certificates from rural districts, it is, nevertheless, an entirely safe 
 conclusion that there are still sections in the United States which are so 
 seriously afflicterl with malarial disease as to challenge com[)arison with 
 some of the most unhealthy portions of other countries cfiually afllicted 
 with malarial disease.* 
 
 Subject to the caution that all international malaria mortality statis- 
 tics require to be accej)ted and used with extreme care, the available 
 official data have been l)ri('fly summarized in Table I of the .Vppendix. 
 According to this tal)Ie the highest death rate from malaria at the 
 present time (that is, the period ending generally with 1914 or 1915) 
 prevails in the i.sland of Mauritius, where during 1910-1914 it reached the 
 extreme figure of 1176.9 per 100,000 of jxjpulation. Among other 
 conspicuous illustrations of an excessive incidence of nudaria mention 
 may be made of Nicaragua, where during 1908-1911 the mortality rate 
 reached 727,5, British Honduras, where during 1914-1915 it reached 
 589.7, British Cuiana, where during 1911-1915 it reached 421.0, the city 
 of (iuayaquil, Ecuador, where the rate is 424.0, aiid finally the IMiiiip- 
 pine Islands, where during the [)eriod 1909-191.S, regardless of active 
 efforts at eradication, the rate still maintained the high level of 397,5. 
 The extraordinary significance of these figures may best be realized 
 when it is stated that for Italy, which, in its southern portion at 
 least, is generally considcreil intensely mahiri;d, the mortahty during 
 1909-1913 was only 10.0 per 100,000, and even among the Euroinrun 
 [)opuIation of Algeria, which formerly w.is (onsideretl (>xtremely un- 
 healfhful, in fact, the grave of Europeans sellliMg in tin* interior or 
 
 ♦Mortality from Muluria in Seven Coiinlif* of Soiilhrrn MiMniiri, lOIUIOII 
 
 I>*alk> lUt* |Mt 
 
 ToUl Irani IW.uuo 
 
 Counly HnliuUlInn MkUrla Tu^lMlnn 
 
 Dunklin l.lO.TBfl .n«M tfM 7 
 
 Butirr 80,710 154 178 7 
 
 Proiijiot 80..i07 141 I7« • 
 
 Stodilanl IM.OO.'. 178 l4A.t 
 
 Nrw.M«<lriil 80.l»4.i 1*1 IS9 t 
 
 Scolt »0.00< »* M 3 
 
 MiMiuippi «l,«04 S8 04 I 
 
 ScvenCoHnlir. 6M,S«4 I.W4 lOK ■ 
 
 AS 
 
S TA TIS TICAL CONSIDER A TIONS 
 
 engaged in colonization work, the malaria mortality was only 47.6 during 
 the five years ending with 1912.* 
 
 It is realized, as said before, that these statistics are not conclusive. 
 They have reference chiefly to large areas, regardless of the fact that 
 malaria is almost invariably a strictly localized health problem. It has 
 seemed best, therefore, for the purpose of a public discussion to draw 
 particular attention to the malaria death rate of large cities, and, granting 
 that the statistics are occasionally impaired by institutional admissions 
 from the surrounding country, the data are in all probability, at least 
 for general purposes, more useful and conclusive than the data for 
 countries at large. The malaria mortality statistics of fourteen 
 representative cities throughout the world have been brought to- 
 gether in Table II of the Appendix, for the purpose of emphasizing the 
 wide range in malarial incidence in sections where the disease has 
 been endemic for many years and the considerable actual and relative 
 reduction in the malaria death rate in localities where the disease has 
 been brought gradually, if not as yet entirely, under effective control, f 
 
 Among other astonishing illustrations of the truly remarkable progress 
 achieved in consequence of the furtherance of antimalarial measures 
 it is shown, by comparing the malaria death rate of Havana, Cuba, 
 for 1900-1904, when it was 49.0 per 100,000 of population, with the 
 corresponding death rate for 1910-1914, when it was 2.4 per 100,000, 
 or practically negligible. The reduction achieved during the period 
 under consideration was equivalent to 95.1 per cent. In St. Thomas, 
 Danish West Indies, there has been a corresponding reduction in the 
 mortality from malaria during the same period of 88.8 per cent., in 
 Rio de Janeiro, Brazil, of 86.5 per cent., and in Colombo, Ceylon, of 84.9 
 per cent. These are, indeed, most gratifying and absolutely convincing 
 evidences of a possible further reduction under efficient and continued 
 antimalarial efforts, more or less in conformity to the principles of 
 malaria eradication as set forth in the plan recommended to the National 
 Committee on Malaria. 
 
 Since the results attained at Panama are the classical illustration of 
 the truly marvelous possibilities of malaria control, it may be pointed 
 out in this connection that, comparing the malaria death rate of Panama 
 City during the period 1901-1905, when it reached the almost incredible 
 figure of 973.5 per 100,000 of population, with the average mortality, of 
 159.9, of the city during the five years ending with 1915, there was an 
 actual reduction in the malaria mortality of Panama City during the 
 American administration, as compared with the former native or French 
 
 •The morbidity from malaria in the jails of India has been reported upon for many years. Combining 
 the returns for the several provinces, the admission rate from malaria per thousand of average daily strength 
 has been reduced from 298.5 during 1894-1898 to 199.5 during 1904-1908 and 117.3 during 1914. The lowest 
 rate on record was reported for the year 191'2, when it was 105.0, followed by a rate of 108.'2 during 1913. 
 
 tThe general subject of village and town sanitation in relation to malaria and other diseases extended by the 
 mosquito is described in some detail in "The Principles of Hygiene as Applied to Tropical and Sub-tropical 
 Climates," by W. J. R. Simpson, London, 1908. 
 
 54 
 
S TA TIS TICAL COXS ID ERA TIOXS 
 
 administration, of 813.6 per 100,000 of population, equivalent to 83.6 per 
 cent. In Sao Paulo, Brazil, during the same period of time, the 
 mortality from malaria was reduced 83.1 per cent. In Manila, Philippine 
 Islands, it was reduced 79.1 per cent.; in Catania, Italy, 77.9 per cent.; 
 and in New Orleans, La., 74.7 per cent. Where so much ha;; been achieved 
 within so relatively short a period of time, it is apparently a foregone con- 
 clusion that decidedly better results can be secured under still more 
 advanced and well-considered methods of administration and control in 
 the countries or cities where the disea.se at the present time coutiiuies to 
 prevail to a more or less alarming degree. Thus, in Kingston, Jamaica, 
 the malaria mortality has been reduced from 248.6 per 100,000 of poi)ula- 
 tion during 1901-1905 to 99.7 during 1911-1915, or 59.9 per cent.; but 
 the i)resent rate for Kingston of 99.7 is in marked contrast to the 
 corresponding rate of 20.6 for Manila, of 8.8 for Xew Orleans and of 
 only 2.4 for Havana. In the city of Memphis the average malaria 
 mortality during 1900-1904 was 145.0 per 100,000; during 1910-1914 the 
 rate was reduced to 74.2, or 48.8 per cent. Regardless of the gratifying 
 decrea.se in the malaria mortality of selected cities, it is .self-evident, 
 in view of the low prevailing rates of 8.8 for Xew Orleans and 2.4 for 
 Havana, that the practical possibilities oj complete malaria eradication are 
 as yet far from having been attained. The certainty, for illustration, that 
 the malaria mortality of Memi)his is mat<>rially increased by the negro 
 population, more susccj)tiblc to malarial infection than the white race, 
 merely enipha-sizes the national importance of malaria eratlication, since, 
 on the one hand, the negro element is of the greatest economic impor- 
 tance, and a measurable impairment of its physical efliciencv must .seri- 
 ously react upon the aggregate productive energies of the nation con- 
 sidered as a whole; and, on the other hand, the negro, on account of 
 extreme mobility and extensive migration, tends, perhaps more than any 
 other factor, to s[)read the disease from infected to non-infected localities, 
 as has well been illustrated in malaria outbreaks in northern commu- 
 nities where the anopheles mo.scjuilo is extremely common but ordinarily 
 harmless, because of non-infection. 
 
 Recent malaria niortiilily statistics for tliirt\ -four Aiiicrican cities are 
 briefly summarized in Table IV <»f the .Vppendix. .\ccording to this 
 table the average malaria mortality rate w;us reduced from 8.9 per 
 100.000 for the five years ending with 1904 to only 3.2 during the ti\e 
 years ending with 1914. There was, therefore, an actual reduction «»f 
 5.7 per 100,000 of po|)nlation, ecjuivalent to (54 per cent. The redix- 
 tion was most niarke(| in Key West, where the rate was reduced from 
 32.5 to only 2.0, or 93.8 per cent, .\mong oIIht conspicuous aehieve- 
 ment.s are the results secured in Wilmington, N. ('.. where the rule was 
 reduced 81.9 percent., and in Paducah. Ky.. where tlie rale wits mhicetl 
 57.2 per cent. The one suggestive exception to the rule of a geiuTal 
 reduction throughout the coimfry \va> Mobile. Ala., wlu-re the mortality 
 
 56 
 
STATISTICAL CONSIDERATIONS 
 
 from malaria during the decade under review increased from 51.6 per 
 100,000 during the first five years to 60.4 during the last five years, or 
 17.1 per cent.* 
 
 The statistical evidence as regards the possibilities and future achieve- 
 ments of malaria eradication may, therefore, be considered absolutely 
 conclusive. The statistical method, however, can be utilized, to much 
 greater advantage than has heretofore been realized, in the scientific study 
 of the geographical distribution of the disease and such elementary con 
 siderations as age, sex, race and occupation in their relation to climate, 
 soil, topography, etc. In the United States the mortality from malaria 
 falls chiefly upon the earlier ages, but the morbidity often seriously im- 
 pairs social and economic efficiency in adult life. 
 
 Malaria also complicates many other diseases, even pregnancy and 
 surgical operations. Malaria is, therefore, a much more important 
 problem than is generally recognized by the public, more or less 
 indifferent to its occurrence, upon the false assumption that chills 
 and fevers have to be endured as a matter of course and in general are 
 of no particular medical significance. The investigations which have 
 been made by the Rockefeller Foundation and the United States Public 
 Health Service and the conservative estimates as regards the economic 
 loss arrived at by Prof. L. O. Howard and the equally important and sug- 
 gestive observations on the mortality and cost of malaria by Sir Ronald 
 Ross tend to emphasize the economic aspects of malaria eradication 
 and the lamentable economic waste sustained by a given population or 
 section in consequence of an excessive incidence of malarial disease. 
 
 The differential diagnosis of malaria is, however, exceedingly complex. 
 Malaria complicates so many other important diseases that in infected 
 sections it is rarely absent, at least in a latent form. Its relation to 
 nephritis has been admirably described by William Sydney Thayer, in 
 1908. It is a well-known fact that the mortality from Bright's disease 
 is much higher among the colored population of the Southern States than 
 among the whites, a condition which in a measure must be ascribed to 
 malarial infection. 
 
 The subject of blackwater fever lies outside the present discussion. 
 Malarial hematuria, or hemoglobinuric fever, is of a much lesser degree 
 of frequency occurrence in the Southern States at the present time than 
 in former years. According to Craig, "Hemoglobinuric fever has no 
 etiological connection with the malarial fevers," but he includes a brief 
 discussion of the disease in his treatise on the malarial fevers, for the 
 reason that "the disease most frequently occurs in malarious regions 
 and very often in the subjects of malarial infection." He points out 
 that, like kala-azar, "this disease has long been considered as due 
 to malarial infection, but the more we inquire into its etiology, its 
 
 ♦During very recent years the malaria death rate of Mobile has decreased as follows: 1911, 77.8; 191*2 
 67.1; 1913, 53.1; and 48.6 during 1914. 
 
 5(5 
 
S TA TIS TICAL CONSIDER A TIOXS 
 
 distribution, symptomatology and pathology, the more must we become 
 convinced that the malarial nature of tiie condition is far from certain, 
 and that the evidence points to it being a separate disease entity, in all 
 probability caused by a hitherto undiscovered organism." This con- 
 clusion, however, is strongly opposed by Drs. Decks and James in their 
 Report on Hemoglobinuric Fever in the Canal Zone, published in 1911. 
 On the basis of "230 cases subjected to critical analysis, the authors 
 conclude that "The amount of previous malaria, whether recent or 
 remote, determines the prevalence of hemoglobinuric fe\cr, and from 
 these conclusions it is very evident that malaria is a predisposing factor 
 of great importance in hemoglobinuric fever." The subject of black- 
 water fever in the tropical African dependencies of Great Britain is 
 annually reported upon to Parliament in considerable detail, suggestive 
 of corres{)onding sjiccial investigations in excci)tionally infected locali- 
 ties in the United States. An exceedingly valual)le scientific contril)U- 
 tion to the subject of blackwater fever is a report by ('apt. S. R. 
 Christophers and Dr. C. A. Bentley, of the India medical service. i)ub- 
 lished as "Scientific Memoir Xo. 3.5" of the Medical and Sanitary 
 Departments of the Government of India, in ]!)()!>. The results of this 
 investigation are summarized in the statement that if the conclusions 
 as regards the malarial origin of blackwater fever are correct, "the 
 profjhylaxis of the condition is simply the f)revention as far as possible 
 of malarial infection, and the i)rompt and efhcient treatment of this 
 di.sea.se, with the view to prevent the occurrence of relapses." The 
 point of view that excessive quinini/.ation is a cau.se of blackwater 
 fever is not accepted, but, quite to the contrary, it is held that the 
 systematic use of (|uinine is more or less effective for propliylactic 
 I)urposes. A very useful general treatise on blackwater fe\'er is l)y 
 A. G. Newell, M. D., late special deputy health officer of the Bombay 
 Municipality, etc., in which blackwater fe\-er is defined as "bilious 
 malignant tertian ague," and the prophylactic treatment advised is a 
 well-considered method of (|uininizali<ni. cornbincd with protection 
 against mos(iuitoes to safeguard the jjatient against reinfection. 
 
 The a.scertaimnent of the true rate of incidence of malaria in a given 
 area is of the first iriiporlatice, since there is entirely too nuich reliance 
 uj)on general data, which are more or less misleading and inconclusive. 
 Thus, for illustration, the malaria mortality rate of the United Slates 
 registration area of iM per 1()(),()()() of |)opulation is absolutely incon- 
 clusive; whereas the excessive mortality from malaria in the south- 
 eastern river counties of Missctiiri of KJS.H is a lru<' measure of the 1«kmiI 
 imi)ortance of the malaria j)roblcm and the al>s<»lulc urgency of «'lTcctive 
 methods of era<lieation and control. Kven in that particular area, 
 limited to only seven <-ou>ilies, the rate is as low as (54.1 in Mississippi 
 County and as high as «..'!)(;. 7 in Dunklin Comity; in fact, in these 
 very counties, the rale of lo<al incidenc*- will l»c found to vary widely 
 by towns, or settlements or drainage districts, and comparatively nearby 
 
S TA TIS TICAL COXSIDERA TIONS 
 
 sections may, on the one hand, be relatively free from the disease and, 
 on the other, subject to an exceedingly high rate of frequency* 
 
 All local investigations or malaria surveys to be scientifically conclusive 
 require to be made with reference to climatoiogical and topographic con- 
 siderations. In the Southern States the highest mortality from malaria 
 prevails, as a rule, during the month of September, as regards both the 
 white and the colored population, and the lowest rates of frequency pre- 
 vail generally during the month of February, after proper correction is 
 made for the variations in the length of the months. In Havana, how- 
 ever, the maximum mortality from malaria occurs in July, and the 
 minimum in the month of February; whereas in the Panama Canal 
 Zone the maximum rate prevails in July, and the minimum rate in April, t 
 
 The correlation of malaria to meteorological conditions has been 
 attempted with a varying degree of success. There are reasons for believ- 
 ing that there is no specific correlation conforming to the principle of a gen- 
 eral natural law, but that rather when such a correlation is found appar- 
 ently to exist it is interdependent with local conditions. A minute analysis 
 of the meteorological facts is, therefore, absolutely essential, if the conclu- 
 sions arrived at shall square with the conception of scientific accuracy. 
 In Manaos, Brazil, + for illustration, a maximum malaria frequency coin- 
 cides with a minimum rainfall, which is in marked contrast to the expe- 
 rience observed in other sections of the world. It is self-evident that 
 mere rainfall as such can not be a direct causative factor, but that it is 
 rather the opportunity provided for the breeding of the anopheles mos- 
 quito, which tends directly to increase the malaria death rate. When the 
 rain falls in very large quantities during comparatively short periods of 
 time, the very excess in rainfall may in itself be the means of destroying 
 
 *0f special interest in this connection are the Soil Surveys of Pemiscot County, published by the United 
 States Bureau of Soils in 1912, of Stoddard County, published in 1914, and of Dunklin County, published in 1916. 
 Also the Special Reports on the Little River Drainage District of Missouri, by Isham Randolph, Consulting 
 Engineer, Chicago, 111., and a Preliminary Report on the St. Francis Valley Drainage Project in Northeastern 
 Arkansas, by Arthur E. Morgan, Office of Experiment Stations, Washington, D. C, 1909. For another 
 excellent illustration of the practical value of thoroughgoing local malaria studies, reference may be made to the 
 address on Malaria in Greece, by Sir Ronald Ross, published in the Smithsonian Report for 1908. 
 
 fSee in this connection special publication No. 3, "The Mortality of the Western Hemisphere," published by 
 The Prudential Insurance Company of America, on the occasion of the Panama-Pacific International Exposition, 
 Sau Francisco, 1915. 
 
 {RAINFALL AND MALARIA MORTALITY 
 
 Manaos, Brazil, 1907-1914 Panama City, 1908-1914 
 
 Month Rainfall Deaths from Percentage Rainfall Deaths from Percenta^tt 
 
 (inches) Malaria Distribution* (inches) Malaria Distribution* 
 
 January 8.4 253 6.3 0.9 80 9.6 
 
 February 7.8 293 8.0 0.9 63 8.3 
 
 March 10.0 328 8.2 0.4 49 5.8 
 
 April 8.5 303 7.8 3.1 41 5.1 
 
 May 7.0 345 8.6 9.1 53 6.3 
 
 June 3.4 398 10.3 6.8 71 8.8 
 
 July 1.3 479 11.9 7.2 84 10.0 
 
 August 1.1 472 11.8 8.3 80 0.6 
 
 September 1.7 365 9.4 7.1 67 8.8 
 
 October 4.0 276 6.9 10.0 78 9.4 
 
 November 5.2 205 5.3 9.1 66 8.1 
 
 December 8.6 220 5.5 6.5 90 10.7 
 
 Total 67.0 3,937 100.0 69.4 822 100.0 
 
 •Adjusted for varying length of months. 
 
 58 
 
STATISTICAL COXSIDERATIOXS 
 
 breeding-places of anopheles mosquitoes; and the subsequently rapid 
 drying of the soil and the rapid evaporation of the standing water may 
 aid in reducing malaria frequency. As a general rule, however, a heavy 
 average rainfall, fairly normally distributed throughout the year, coincides 
 with an excess in malaria frequency, provided the temperature condi- 
 tions, humidity and wind force are all favorable.* 
 
 The malaria death rate is also materially modified by race and the 
 migration of people from non-malarial countries to more or less intensely 
 malarial regions. There can be no question of douljt but that some form 
 of natural immunity or protection against malaria is acquired, if not other- 
 wise than through the almost universal malarial infection in infancy in 
 countries subject to an extremely high malaria rate, f Race is, therefore, 
 of serious importance, as is best illustrated by the data for the southern 
 part of the United States registration area, for which the returns are 
 apj)roximately trustworthy and according to which the average malaria 
 death rate was 8.0 per 100,000 for the white population, against tiO.O for 
 the colored. The contrast is much less marked in Cuba, where white 
 males, for illustration, have a malaria death rate of ^Z'i.'i, against a malaria 
 death rate for the colored of 31.8, and where the white female malaria 
 death rate is 16.5, and the colored 27.8. It has been found by 
 experience in the West Indies, particularly in Jamaica and British 
 Guiana, that the coolie immigrants from the East Indies are exceed- 
 ingly liable to malaria, so nuich so that during 100.5-1!)11, for 
 illustration, the East Indian population of British Guiana experienced 
 a malaria death rate of 547.() per 100,000 of population. Since this 
 element is imj)orted solely for i)lantation [)urp()ses the impairment in labor 
 efficiency resulting from malaria must reach extraordiii;iry prijportions, 
 which, unfortunately, are imperfectly realized or indifferently regarded 
 by the governments and the i)lantation element responsible for malaria 
 eradication and health i)rotcction otherwise in the countries referred to. 
 As a general statcineiil it may l)e asserted that most of the hospital pop- 
 ulation in the island of Jamaica, on account of malaria, consists of East 
 Indians, although this element constitutes but a relatively small propor- 
 tion of the plantation labor of the island. In contrast, the remarkable 
 achievement in liealtli promofion and sanitation in Hawaii is the result 
 of active and energ<'tic administrative mejLsures in coordination with 
 the efforts of the sugar-i)lanters of the island, which have reduced the 
 death rate from all causes and from such diseases as most commonly pre- 
 vail among the immigrant class to normal and cxcn subnormal propor- 
 tions. 
 
 These very general statistical considerations are merely inlcntled to 
 emphasize the urgency and practical usefulness of a lliorough and 
 
 •The annual variations i>f niiiluria witli s|>r)'iii| rrfrrrnrr to rninrnll linve hrrii r. i-tI. .| ui...ii in aom* dftailin 
 111. I"ir«t Kr|K>rt on Malurin in HrnKnl. I.v Mtt). A. I«. Fry. M. D. <«l. ulla. l»l<. 
 
 tSrc A ri.a for a .National C'ominiltcc on Ihr Kra<li<ation .f M .1 .n.. Vnr ihU.,n> U^,i,<;it and Surftrt, 
 Journal, Aiiguil. 1010. (or ujrful adililiunnl lUitiatiral iiiformntion. 
 
 59 
 
S TA TIS TJCAL CONSIDERA TIONS 
 
 qualified analysis of the mortality and morbidity from malaria through- 
 out that portion of the world in which the disease is known to exist to a 
 more or less serious degree.* The practical importance of malaria 
 eradication is so perfectly obvious that it should not require an extended 
 argument in support of the plea and the ])lan of the National Committee 
 on Malaria in the furtherance of the implied obligation, governmental 
 or otherwise, contained in the resolution adopted by the Second Pan- 
 American Scientific Congress. It is not going too far to say that malaria 
 eradicatioyi is essentially a labor problem of the first importance; that an 
 enormous amount of labor inefficiency due to malaria continues to hinder 
 the progress of semi-tropical and tropical countries, which, if brought 
 under control and completely done away with, must needs assist pro- 
 foundly in the reclamation of the tropical regions for the practical needs 
 of the world at large, j What has been done in this direction by the 
 United Fruit Company in the gradual eradication of malaria from its 
 plantations and from among its white employees from the United States, 
 required for administrative purposes, is deserving of special consideration 
 as perhaps the best illustration, next to the classical results secured in 
 Panama, of the practical achievements and future possibilities of malaria 
 eradication in the western world. % Even under present conditions, regard- 
 less of the progress which has been made in Banes, Cuba, 49 per cent, 
 of the cases treated in the hospitals of that company are on account of 
 malaria, in Guatamala the proportion was 42 per cent., and in Tela, 
 Honduras, 39 per cent. (1915). Malaria has not been completely eradi- 
 cated from the Isthmus of Panama, nor is it likely that for a long time the 
 disease will be entirely eradicated from any section of the world; but its 
 complete eradication is an ideal which need not disturb those who are 
 working for the attainment of a material modification of and improve- 
 ment in existing conditions. There is malaria in practically every state 
 in the Union and in practically every country of the world. Wherever 
 anopheles mosquitoes exist, there possibilities of malarial outbreaks exist 
 also, provided, of course, climatological conditions are favorable. The 
 best practical illustration of this conception of malaria eradication and 
 control as a world problem is to be found in the experience which has 
 resulted from the European War, and which, particularly in the case of 
 
 •It is an error to assume that malaria prevails throughout the tropics, as pointed out in a note of the Journal 
 of the American Medical Association under date of April 25, 1914. "According to the report by Maj. Brooke, of 
 the United States Army, Cebu in the Philippines is free from malaria, although the anopheline mosquito has 
 been found there, and it is surrounded by the zones in which malaria is epidemic. Brooke refers to the sugges- 
 tion by Manson 'that there are some places free from malaria yet surrounded by epidemic zones, as in the case 
 of Cebu, because in that particular area food conditions for the mosquito can exist which are inimical to the 
 growth of parasites in their bodies.'" (See, also, "The Tropics," by C. R. Enock, New York, 1915.) 
 
 tThe relation of malaria to agriculture has been made the subject of a special investigation by the Bureau of 
 Entomology, published by the United States Department of Agriculture. In Madison Parish, La., it was found 
 that twelve families cultivating 286 acres of land lost an aggregate of 88 weeks' time during the crop-growing 
 season on account of malaria, or more than seven weeks per family. The financial loss was estimated as $24 
 per family. 
 
 |^'or a full account of the sanitary achievements of the United Fruit Company, see "Conquest of the 
 Tropics," by Frederick Upham Adams (New York, 1914), and the annual reports of the company's medical 
 department for the years 1909-1915. 
 
 60 
 
.S TA TIS TICAL COXSIDERA TIOXS 
 
 France and the Mediterranean countries, has resulted in serious complica- 
 tions as regards the medical treatment of the wounded and the phj'sical 
 efficiency of the forces. With commendable foresight, therefore, the 
 British War Office has issued an admirable handbook on "Some 
 Medical Diseases in the Mediterranean War Area," in which malaria 
 is given the most extended consideration of all the diseases con- 
 sidered in detail. More important, therefore, than cerebrospinal fever, 
 typhus fever, paratyphus, relapsing fever, heat-stroke or dysentery is 
 malaria in the southern war area, and, as well said in the work referred to, 
 "A considerable number of cases of malaria, that mod Protean of all 
 diseases, has occurred at Cape Hellas and Suvla Bay." Malaria is not 
 likely to be of deciding importance in the present European War, but it 
 may under given conditions prove as serious a factor as regards local 
 conflicts as the disease unquestionably constitutes in the progress or 
 decay of given localities or states. 
 
 The importance of malaria as a factor in military efficiency has been 
 recognized l)y all authorities on military hygiene. The early United 
 States Army experience, particularly in the Southern States, proves con- 
 clusively the extensive and serious prevalence of intermittent and remit- 
 tent fevers and its relation to the resulting inefficiency or incajjacity 
 of the troops. As early as 1808, Edward Cutbush, M. D., of the United 
 States Xavy, in his observations on the means of i)reserving the health 
 of the soldiers and sailors, states that "\\'e learn frt)m experience that 
 fevers are little known in rough, hilly countries, where water flows with 
 a rapid course; while we likewise know, that they are common in low and 
 champaign countries, where water stagnates, or has only a sluggish 
 motion: indei)en(ieiit of which, those situations, which are in the neigh- 
 borhood of swamps or near oozy banks of large rivers, have always l)een 
 observed to be particularly liable to such diseases." Even more sug- 
 gestive arc the "Medical Sketches of the Campaigns of 181'-2-1814," by 
 James Mann, M. I)., published in Dcdiiam, ISUi. These sk(>lch('s in- 
 clude obser\ali(»ns on the extensive and serious prevalence of inter- 
 mittent and remittent fevers in Burlington, ^'l., and on the Niagara 
 frontier. Attention is directe(l lo the iniportance of drainage and 
 (•ulti\'af i«»n in their rdalinn to l'e\-er occurrcnc**, the statement being, 
 in i)art, thai "In })ri)j)()rl ion as (•nili\ali()n of the earth is exiendcfl by 
 op<'ning the forests and draining the lands, so will climate be impr<)\<'<i. 
 and its end<'mic diseases <lisappear. The heavy fogs of lakes and large 
 rivers, which are impeded and suspended over their borders by wikxI- 
 lands until a late hour of the t\;\\\ abstract from the body its \ital heaf. 
 and snbj<'cl the inhabilatils lo iiilcrmil f cut fc\'ers, and other anlnninal 
 diseases, as dysentery and diarrhea. They, however, are less fre(juent 
 at those jjoints, on the lake sh(»res, where cultivation has made some 
 progress, .-ind iiaxc disap|)ean*d where the lands are extensi\-ely impro\<'d. 
 'i'hese autumnal diseases, which are now considered endemic in new 
 settlements on the frontiers, will vanish as the forests are snl)dMcd, :uu\ 
 
 61 
 
S TA TIS TICAL CONSIDER A TIONS 
 
 the marshes and swamps drained; while the husbandman will be 
 remunerated by a twofold reward, higher degrees of health as well as 
 accumulation of wealth." 
 
 These observations by a military surgeon of extensive experience are 
 fully sustained by the results of a thorough statistical analysis of the 
 sickness and mortality in the United States for the period 1819-1839, 
 by Thomas Lawson, M. D., Surgeon-General, published in 1840. These 
 early statistical investigations suggest an equally extended analysis of 
 our more recent army experience, with special reference to the different 
 army posts and fields of military occupation in tropical territory. The 
 statistics of fever morbidity and mortality during the Civil War form an 
 important contribution to medical history and experience, and even 
 at the present time the observations on Malarial Influence on Army Life 
 and Efficiency by Brigadier-General William A. Hammond, Surgeon- 
 General, United States Army, published in 1863, are of value, regardless 
 of the fact that they rest upon fundamentally erroneous assumptions 
 as to the nature of malarial disease and its then unknown transmission 
 from insects to man. 
 
 The truly enormous progress which has been made in malaria eradica- 
 tion and control during the long intervening period of years is reflected 
 in the timely observations on the subject by Edward L. Munson, M. D., 
 late Chief Medical Department, United States Army, in his treatise on 
 "The Theory and Practice of Military Hygiene," published in 1901. 
 The observations of Dr. Munson, which, it requires to be considered, 
 precede the practical application of the discovery by Sir Ronald Ross 
 of the insect transmission of malaria, are briefly summarized, with 
 special reference to army experience, as follows: 
 
 Malaria has ravaged armies in every age and climate, and has frequently 
 modified military operations or brought about their failure. Rome was saved 
 from capture by malarial fevers, which so scourged the besieging Gauls under 
 Brennus as to cause their retreat. In the year 208, the Roman army in Scotland 
 lost 50,000 men out of a total of 80,000 from this cause. No military disaster 
 caused by malarial infection was more complete, however, than that of the 
 British expedition to the island of Walcheren, in 1809. On this occasion it has 
 been said that the British were conquered before the battle. Out of an effective 
 force of 39,219 there succumbed to the fever, between August 28th and Decem- 
 ber, no less than 23,175 men, while after the return to England there were 11,503 
 additional cases. But 217 men, during this disastrous expedition, were kiUed 
 by the enemy. In the Seminole War, in Florida, our troops suffered severely 
 from malarial infections. In the French army before Sebastopol there were 
 20,623 cases, with 2,179 deaths. In the Union forces, during the Civil War, 
 there were 1,314,744 cases of malaria, with 10,062 deaths, giving a mortality of 
 3.92 per thousand strength. "But though the mortality from these fevers was 
 comparatively light, their influence in detracting from the efficiency of the arrny 
 was very great" — as well as largely influencing the rates of discharge for dis- 
 ability on account of resulting anemia and chronic malarial poisoning. The 
 so-called "Chiekahominy fever" was particularly severe in its effects. Malarial 
 fevers prevailed in the French army during the Italian War and the occupation 
 of the Papal States. Ashmead states that 5,995 Japanese soldiers, sent to 
 Formosa in 1873, furnished 6,105 admissions to hospital, for continued malarial 
 fevers, in a single year. In the French expedition in Madagascar, in 1895, out 
 of a force of 22,850 men — combatants and carriers — there were 7,498 deaths 
 
 62 
 
S TA TIS TIC A L COXS ID ERA TIOXS 
 
 from disease; a mortality of about 33 per cent. Nearly aU the deaths were from 
 malarial fevers. During this expedition only 7 men were killed by the enemy 
 and but 94 wounded. In the same year, a Spanish expedition in the Philippine 
 Islands was scourged by malarial fever. During the last insurrection in Cuba, 
 the Spanish forces were largely depleted by malarial infections of a severe type ; 
 the admissions to hospital for this cause, during the year 1897, amounting to 
 420 per thousand strength. In 1898, after the capture of Santiago, one-half of 
 our forces in Cuba were incapacitated for duty at the same time by reason of 
 malarial fevers. This grave condition of affairs evoked an appeal to the War 
 Department, signed by all the officers of higher rank, for an immediate remo\'al 
 of these troops to a more healthy locality — using the sentence: "This army 
 must be moved or perish." 
 
 Dr. Munson directed attention to the fact that since the Civil War tlie 
 admissions for malaria for the entire army had been reduced from a 
 maximum of 793.8 per 1,000 strength in 1868 to 78.9 per 1,000 in 1807. 
 In consequence of the Spanish American War, of 1898, the admission 
 rate on account of the exposure to malarial infection in the tropics was 
 increased to 694.6 per 1,000. More recent statistics for the United 
 States Army and Xavy are briefly summarized in the two tables following: 
 
 MORBIDITV FROM MALARIA, UNITKD STATES ARMY, 1901-1915 
 Rato per 1.000 Mean Strength 
 
 1901 380.4 1906 122.4 1911 39.6 
 
 1902 272.3 1907 88.7 1912 51.7 
 
 1903 201.2 1908 59.6 1913 33.8 
 
 1904 102.3 1909 49.4 1914 29.4 
 
 1905 122.3 1910 42.2 1915 25.2 
 
 MORBIDITY FROM MALARIA. UNITED STATES NAVY'. 1901-1915 
 Kat»' per 1,000 Mean Strength 
 
 1901 41.4 1906 43.6 1911 12.1 
 
 1902 45.1 1907 31.4 1912 11.6 
 
 1903 32.8 1908 21.8 1913 12.1 
 
 1904 39.1 1909 18.3 1914 17.4 
 
 1905 24.8 1910 11.8 1915... 17.7 
 
 The.se statistics reflect the direct influence of governmental policy 
 ba.sed upon the modern knowledge of the insect transmission of malarial 
 infections. The increase in the navy malaria morbidity rate during the 
 last two years is accounted for by the naval operations in Mexico and 
 the West Indies. The army malaria death rate has been reduced from 
 1.35 per 1,000 in 1900 to only 0.0^2 in 1915. In the navy the mortality 
 from malaria siticc 1901 lias been negligible. 
 
 "^riie j)liysical cflicii iicy of an army is measured or determined by the 
 constantly non-effective rate, that is, the j)roportion of men con- 
 stantly on the sick list. The non-effective rate of the liiiited States 
 Army has been very materially reduced during recent years, but the 
 ideal of .SO per 1.000 has not been attained. During 190!). for illustra- 
 tion, the non-effective rate was 4'-2, which according to Ilavard was 
 equivalent to a lo.ss of 14.5 days from sickness or injury for each soldier, 
 in contrast to an average loss of only 9.7 days for the navy and of 10.4 
 days for the British army. The practical significance of malaria as a 
 basic consideration in problems of military efficiency and national 
 preparedness therefore assumes the importance of a medical, economic 
 and military prol)lem of the first order. 
 
 08 
 
STATISTICAL CONSIDERATIONS 
 
 Table I 
 Mortality from Malaria Throughout the World 
 
 WESTERN HEMISPHERE 
 
 Aggregate 
 
 Country Period Population 
 
 Nicaragua 1908-1911 2,180,000 
 
 British Honduras 1914-1915 88,268 
 
 City of Guayaquil, Ecuador. ... 191 1-1915 420,000 
 
 British Guiana 1911-1915 1,516,710 
 
 City of San Salvador 1910-1914 324,900 
 
 Venezuela 1908-1912 13,525,191 
 
 Trinidad and Tobago 1910-1914 1,715,102 
 
 City of Paramaribo, D. Guiana. 1908-1912 174,775 
 
 Panama Canal Zone 1911-1915 677,792 
 
 Sixteen Cities of Brazil 1909-1913 11,725,980 
 
 Brit. Leew'd and Windw'd Isls. 1910-1914 1,026,879 
 
 Porto Rico 1911-1915 4,675,044 
 
 Costa Rica 1911-1915 1,999,545 
 
 Jamaica 1911-1915 4,317,064 
 
 St. Thomas, Danish W. 1 1911-1915 53,050 
 
 Cuba 1910-1914 11,561,416 
 
 United States Reg. Area 1910-1914 302,835,133 
 
 EASTERN HEMISPHERE 
 
 Mauritius 1910-1914 1,842,561 
 
 Straits Settlements 1910-1914 3,596,554 
 
 Zanzibar Qity 1910-1914 176,320 
 
 Philippine IsT^ds 1909-1913 29,472,283 
 
 City of Freetown, Sierra Leone . 1910-1914 170,000 
 
 Hongkong 1911-1915 1,999,524 
 
 Ceylon 1910-1914 20,817,228 
 
 Algiers (Europeans) 1908-1912 3,712,365 
 
 Spain 1906-1910 96,717,000 
 
 Italy 1909-1913 173,356,885 
 
 Portugal 1905-1909 28,817,465 
 
 UnionofS. Africa (Europeans). 1912-1914 4,018,253 
 
 France 1908-1912 197,198,000 
 
 Commonwealth of Australia .. . 1909-1913 22,583,681 
 
 Table II 
 
 Deaths from 
 Malaria 
 
 15,859 
 
 491 
 
 1,781 
 
 6,385 
 
 1,223 
 
 41,331 
 
 3,754 
 
 257 
 
 949 
 
 12,878 
 
 997 
 
 3,793 
 
 1,251 
 
 2,278 
 
 15 
 
 2,535 
 
 7,859 
 
 21,686 
 
 19,818 
 
 867 
 
 117,139 
 
 428 
 
 1,667 
 
 11,304 
 
 1,768 
 
 10,930 
 
 17,399 
 
 1,874 
 
 141 
 
 2,029 
 
 174 
 
 Kate p«r 
 
 100,000 
 Population 
 
 727.5 
 
 589.7 
 
 424.0 
 
 421.0 
 
 376.4 
 
 305.6 
 
 218.9 
 
 147.0 
 
 140.0 
 
 109.8 
 
 97.1 
 
 81.1 
 
 62.6 
 
 52.8* 
 
 28.3 
 
 21.9 
 
 2.6 
 
 1176.9 
 
 551.Qt 
 
 491.7 
 
 397.5 
 
 251.8 
 
 83.4 
 
 54.3 
 
 47.6 
 
 11.3 
 
 10.0 
 
 6.6 
 
 3.5 
 
 1.0 
 
 0.8 
 
 A Decade of Malaria Mortality Reduction in Large Foreign Cities 
 
 City 
 
 Habana 
 
 St. Thomas Is.. 
 Rio de Janeiro 
 
 Colombo 
 
 Panama City. . 
 
 Sao Paulo 
 
 Manila 
 
 Catania 
 
 Kingston 
 
 Calcutta 
 
 Rome 
 
 Port of Spain . 
 Hongkong . . . . 
 Bahia 
 
 Cuba 
 
 Dan. W.I... 
 
 Brazil 
 
 Ceylon 
 
 Panama 
 
 Brazil 
 
 Philippine Is. 
 
 Italy 
 
 .Jamaica 
 
 India 
 
 Italy 
 
 Trinidad . . . . 
 China (Br.).. 
 Brazil 
 
 1900-1904 
 1900-1904 
 1900-1904 
 1900-1904 
 1901-1905 
 1899-1903 
 1902-1905 
 1899-1903 
 1901-1905 
 1900-1904 
 1899-1903 
 1900-1904 
 1901-1905 
 1899-1903 
 
 Death Rate 
 
 from Malaria 
 
 per 100,000 
 
 Population 
 
 49.0 
 
 334.8 
 
 152.9 
 
 244.4 
 
 973.5 
 
 34.3 
 
 98.4 
 
 23.5 
 
 248.6 
 
 676.5 
 
 16.6 
 
 116.3 
 
 126.5 
 
 157.6 
 
 1910-1914 
 1910-1914 
 1910-1914 
 1910-1914 
 1911-1915 
 1909-1913 
 1912-1915 
 1909-1913 
 1911-1915 
 1910-1914 
 1909-1913 
 1910-1914 
 1911-1915 
 1909-1913 
 
 Death Rate 
 
 from Malaria 
 
 per 100,000 
 
 Population 
 
 2.4 
 
 37.6 
 
 20.7 
 
 37.0 
 
 159.9 
 
 5.8 
 20.6 
 
 5.2 
 
 99.7 
 
 291.8 
 
 8.9 
 
 63.9 
 
 83.4 
 
 123.7 
 
 95.1 
 88.8 
 86.5 
 84.9 
 83.6 
 83.1 
 79.1 
 77.9 
 59.9 
 56.9 
 46.4 
 45.1 
 34.1 
 21.5 
 
 ♦During these years were recorded in Jamaica as due to "fevers" without distiuction 15,658 deaths, giving 
 a rate of 362.7 per 100,000 of population. 
 
 tThere were, also, in the Straits Settlements during this period 23,!J19 deaths from undefined fevers, giving 
 a rate of 645.0 per 100,000 of population. 
 
 64 
 
S TA TIS TICAL COXSIDERA TIOXS 
 
 Table III 
 Mortality from Malaria in Italy— 1894-1913 
 
 Period 
 
 1894-1898. 
 1899-1903. 
 1904-1908. 
 1909-1913. 
 
 AgEreiirate 
 Population 
 
 Deallu from 
 .Malaria 
 
 157,530,358 
 
 69,108 
 
 102,555,072 
 
 58,659 
 
 166,876,011 
 
 28,888 
 
 173,587,368 
 
 17,399 
 
 Rate per 
 100,000 Pop. 
 
 43.9 
 36.1 
 17.3 
 10.0 
 
 Table IV 
 
 A Decade of Malaria Reduction in Thirty-four Cities of the 
 
 United States 
 
 1900-1904 1910-1914 
 
 Kate per Rate per Perctatag* 
 
 AefCrepate Total 100,t>l>0 Aetp-egate Toul 100,000 of 
 
 City Population Deaths Population Population Deatha Population DecreaM 
 
 Key West, Fla 92,33G 30 32.5 102,317 2 2.0 93.8 
 
 Richmond, Va 439,580 89 20.2 C5C,759 12 1.8 91.1 
 
 Boston, Mass 2,873,433 29 1.0 3,530,050 5 0.1 90.0 
 
 Providence, R. 1 924,058 63 6.8 1,170,584 8 0.7 89.7 
 
 Newark, X.J 1,298,300 51 3.9 1,851,221 7 0.4 89.7 
 
 New York City.N.Y. 18,312,405 682 3.7 25,343,167 124 0.5 86.5 
 
 Washington, D.C... 1,448,810 162 11.2 1.713,879 32 1.9 83.0 
 
 Jersey City, N. J 1,084,695 38 3.5 1,408,879 8 0.6 82.9 
 
 Toledo, Ohio 697,791 35 5.0 883,489 8 0.9 82.0 
 
 Wihnington, X. C . . . 109,910 245 222.9 134,073 54 40^ 81.9 
 
 Bridgeport, Conn .. . 387,740 23 5.9 544,995 6 "Tl 81.4 
 
 Baltimore. Md 2,597,020 172 6.6 2,847,798 36 1.3 80.3 
 
 Jacksonville, Fla. .. . 155,886 266 170.6 323,646 110 34.0 80.1 
 
 San Antonio.Texas. . 312,270 178 57.0 531,476 69 13.0 77.1 
 
 New Orleans, La 1,490,336 518 34.8 1,75.3,479 154 8.8 74.7 
 
 New Haven, Conn. . . 567,115 56 9.9 696,624 18 2.6 73.7 
 
 Chicago, III 9,006,276 96 1.1 11,481,145 39 0.3 72.7 
 
 Kansas City, Mo 897,475 GO 6.7 1,329,298 28 2.1 68.7 
 
 Indianai)oIi.s, Ind.. . . 928,845 51 5.5 1,235,255 22 1.8 67.3 
 
 Nashville, Tenn 415,175 128 30.8 563,397 68 12.1 60.7 
 
 Alexandria, Va 73,480 12 16.3 77,538 5 6.4 60.7 
 
 St. Ixjuis. Mo 2,372,644 275 11.6 3,560,1.35 162 4.6 60.3 
 
 riiducah, Ky 100,715 178 176.7 117.49S 89 75.7 57.2 
 
 l'liiladeli)hia. Pa. . 6,737,795 76 1.1 8,030,511 40 0.5 54.5 
 
 Charleston, S. C. .. . 282,220 176 62.4 297,544 92 30.9 50.5 
 
 San Franci.sc-o.Calif. . 1,792,101 50 2.8 2,167,443 31 1.4 50.0 
 
 Memphis, Tenn 528,245 766 145.0 685,525 509 74.2 48.8 
 
 AtlauUi, Ga 496,051 51 10.3 836,074 40 5.5 46.6 
 
 Savannah, Ga 296,243 392 132.3 .332,093 261 78.6 40.6 
 
 Kvansvillo, Ind 305,723 40 13.1 352,075 28 8.0 38.9 
 
 St. Jo.seph,Mo 336,855 19 5.6 400,679 17 4.2 25.0 
 
 Norfolk, Va 294,486 85 28.9 401,396 92 22.7 21.5 
 
 b.uisville, Ky 1.015.310 53 5.1 1,149,419 47 4.1 19.6 
 
 Mobile, Ala 195,.560 101 51.6 268.100 162 60.4 -hH.!* 
 
 Thirty-four cities. .. . 58,896,884 5,846 8.9 76,786,561 2.491 3.2 64.0 
 'Increaac. 
 
 65 
 
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