BUREAU  OF  MEDICAL  SERVICE.
                 international  |U(jibiti<nt,

                             —1876—

  UNITED  STATES  CENTENNIAL  COMMISSION. ^/


   "*» °f ^^'"^                Mtic/ed/ta, Vanuatu Y, ^77-
    Medical Service.                        /            t7

  A. T. GOSHORN, Esq.,
               Director- General.
  Dear Sir,—I have the honor to herewith submit the report of the  Medical Bureau ol
the International Exhibition.
                               Very respectfully yours,
                                      WILLIAM PEPPER, M.D.,
                                                  Medical Director.
645 
     WP,
     ULHVr

      t.t

   REPORT  OF  THE  DIRECTOR
                        OF THE
BUREAU   OF   MEDICAL  SERVICE.
  The functions of the Medical Department were to supply medical
and surgical assistance within the Exhibition grounds ; to advise with
reference to sanitary questions;  and to issue in authoritative form
such information on the sanitary condition of Philadelphia and of the
Exhibition  as might  be desirable.  The  important subjects of  the
drainage and water supply of the Exhibition grounds were placed
entirely under the control of the Chief Engineer of the grounds.
  The Medical  Department was organized in the early part of 1876,
by the appointment of a Medical Director, a staff composed of  six
Medical Officers, and a Secretary, who was also the Resident Physician
at the Hospital in the  Exhibition grounds.

                MEDICAL DEPARTMENT.
                      MEDICAL DIRECTOR,
                    WILLIAM PEPPER, M.D.
                   OFFICERS OF MEDICAL STAFF,
   JACOB ROBERTS, M.D.,           ROLAND G. CURTIN, M.D.,
   S. W. GROSS, M.D.,               HAMILTON OSGOOD, M.D.,
   H. C. WOOD, Jr., M.D.,            DE  FOREST WILLARD, M.D.
                RESIDENT PHYSICIAN' AND SECRETARY.
                 THEODORE HERBERT, M.D.
  [There were also employed a nurse, two apothecaries, and four attendants and clerical
assistants.]

  The  Hospital was  centrally located in I andsdowne Ravine, on
Landsdowne Avenue, between Agricultural and Belmont Avenues.
Its  position was retired, well shaded, and  quite picturesque.   The
    646 
REPORT OF THE DIRECTOR-GENERAL.         647
building was a one-storied frame structure, 64 feet by 32  feet, well Bureau of
lighted and ventilated, and conveniently arranged,  having a large Se*vj".
waiting-room, No. I, 19 feet 6 inches by 19 feet 6 inches ; the office of
the Medical Staff and of the Apothecary, No. 2, 19 feet 6 inches by 12
feet 6 inches ; the office of the Director and Secretary, No. 3 ; the pri- Description
vate room of the  Resident Physician, No. 4;  two wards, Nos. 5 and 6, °
for male and female patients, each 16 feet by 20 feet; two bath-rooms,
and  a private room for  the  nurse.  It was furnished  with  every
necessary convenience and comfort, and  in  every way answered the
purposes for which it was intended.
   The Hospital was first occupied on the opening day of the Exhibi-
tion, May 10, and from that time until November 15, when the Ex-
hibition  was finally closed to the public, the above organization was
maintained  in efficient operation.
   The experience of previous International  Exhibitions has been that
exaggerated statements  are circulated as to the bad  sanitary condi-
tion of the cities in which they have been held ;  and a circular (No. 1) circular No.
was accordingly  issued, April 15, 1876, in which the  sanitary condi-
tion of Philadelphia was fairly represented.*   This circular was widely
distributed, and was extensively reprinted at home and abroad.
   Prior  to the opening of the Exhibition the duties of the Medical
Department were chiefly limited to the care of the employees engaged
in the construction of the various buildings or in the preparation of the
grounds, and  of  the attaches of the  Foreign Commissions, who early Casualty
began to take up their residence within the grounds.  It is a gratify- *™°|]f.ecs
ing fact  that although many thousands of workmen were  engaged for
eighteen months in the construction of the buildings, the number of
casualties was very small.   In  order  to  provide fully for these, Dr.
Herbert was at an early day stationed in a convenient office on the
grounds, so that all  such cases might receive immediate  attention.
As there was  telegraphic communication with  the  nearest general
hospital, that connected with  the University of Pennsylvania,  there
was no delay in having any serious case transferred in an ambulance
to its wards.
   With  the opening of the Exhibition began the active work of the
Medical  Department, but for  the first  few weeks the public evidently
were not fully aware of its existence.   It is probable that  from this
cause many cases  of sickness,  occurring during this time, did not
come to  the Hospital for relief.   This  was remedied by an announce-
* See Exhibit A, Circular No. 1, p. 673. 
648
INTERNATIONAL EXHIBITION, 1S76.
Bureau of
Medical
Service.

Stretchers and
ambulance.
ment,  which was posted throughout the  Exhibition  Buildings and
grounds.*
  Owing to the great number and size of the buildings, and the dis-
tances between them, it was necessary to place stretchers at numerous
points in each of the principal buildings and about the  grounds.   The
guards were  especially instructed to promptly convey  to the hospital
any person requiring medical relief.   In addition to this an ambulance
was kept standing in constant readiness  to be dispatched to any part
of the  grounds for  cases of a more  serious character.   The ambu-
lance was also used in exceptional cases  for conveying patients  to
their  residences  in  the  city, or to one of the neighboring hospitals,
after the hours of the Exhibition,
  For the efficient and satisfactory working of the  Hospital  Depart-
ment the following-  rules were issued  :
Rules of the
Bureau.
Health of
resident
population.
   1. The Hospital building does not contain any exhibit; it is intended solely for medical
purposes, and, as its wards are always occupied, visitors will not be admitted.  Informa-
tion concerning the Department can be obtained from the Resident Medical Officer.
   2. All medical relief furnished at the Hospital building being gratuitous, under no circum-
stances will any remuneration be received for services rendered.  No medicines will be sold,
nor will any be dispensed excepting upon the prescription of the officers of the Department.
   3. In order to avoid undue publicity of personal details, the record of the daily work
of the Hospital furnished to the agents of the public press will embrace only the number
and general character of the cases treated.
   4. No patient will be permitted to remain in the Hospital building over night.  All
patients remaining in its wards at the hour of  closing the Exhibition will be transported to
their residence by the ambulance or by private conveyance.
   5. All employees of the Board of Finance, of the Centennial Commission, and of Foreign
Commissions requiring medical treatment, shall report daily to the Resident Medical Officer,
at such an hour previous to the opening of the Exhibition as he ^hall designate.
   6. Any case  of serious sickness occurring among the employees must be reported
without delay to the Resident  Medical  Officer, who shall immediately have the patient
removed to his own residence or to one of the neighboring civil hospitals.

   In proceeding  to the consideration of the medical statistics of the
Exhibition, it will be convenient to allude first to the sickness occur-
ring among the population resident within the grounds.   In this con-
nection it  is important to determine what was the average extent of
this population during the period of the Exhibition, though it is im-
possible to do this with entire  accuracy, on  account  of the constant
changes in the number of  persons domiciled at  the several  State
headquarters.  It may, however, be estimated that the average  daily
population for the twenty-seven weeks was  1568.  The highest  daily
average was  1817, during  the week ending  May 27, and the lowest
daily average was 1382, during the week ending November 10.
* See Exhibit A, Circular No. 2, p. 674. 
SEr ;s k-
*«**
MEDICAL    SERVICE,
        Presented to the
Statistical Division, Surgeon-General's
   Library, United States Army
        Washington, D. C.
             BT
The Prudential Insurance Co. of America
        Newark, New Jer»«y
64I 
It
Jwudw.
GROUND-PLAN OF HOSPITAL. 

HOSPITAL,  BUREAU OF MEDICAL SERVICE. INTERNATIONAL EXHIBITION, 1876. 
 
REPORT OF THE DIRECTOR-GENERAL.
649
   The population was distributed as follows :                        Bureau of
                                                                    Medical
    Residing at the several restaurants, daily average  .....   256
    Residing at the buildings of the several foreign Commissions, daily average   103
    Residing at the several State buildings, daily average   ....    88     Resident
    In the employ of the United States Government, daily average    .    .    91     popuation.
       "    "    "   Board of Finance:
                                 Centennial Guard, daily average .   802
                                 Firemen, daily average    .    .   175
                                 Janitors and others, daily average.    53
                     Total.........1568

   Before considering the amount of sickness occurring  among this
 population, attention is due to the peculiar conditions involved. In the
 first place, among the numerous  representatives of foreign countries
 quartered within the grounds, most of whom were  sufficiently well
 housed and provided for, there were not a  few who suffered severely
 from the exceptional  weather  of 1876—the keen cold of the early
 months of the year, as well as the intense heat of the summer.  Un-
 fortunately, too, some of those whose native climate would render
 them most susceptible to these extremes were not suitably provided
 for, in either lodging or food. This was particularly the case with the
 Japanese, who numbered about fifty;  and whose dwelling, although a
 beautiful model of Oriental taste and workmanship, was barely suitable
 as  a  residence  during the  cool weather of an ordinary Philadelphia
 spring or fall.  It was a frame structure of the lightest description, with Peculiarities
 no provision for heating excepting a small shallow box, filled with sand, ^eUiTg""6
 placed in the centre of each room, upon which were kept burning a few house.
 small pieces of charcoal.  It may be imagined, therefore, how  ill fitted
 this was as a residence, not only during the  severe winter months, but
 even during April, May,  September, and October. It is to be noted, in
 connection with this mode  of heating the apartments of the Japanese
 dwelling, that, as there was  no outlet for  the fumes  of  the  burning
 charcoal, nor indeed any aperture whatever for  ventilation when the
 rooms were closed, as  they constantly were during cool weather, the
 inmates were subjected to a  most unwholesome  atmosphere.  These
 depressing  influences,  in connection  with  their  meagre  diet, caused
 considerable sickness among the Japanese.  The chief forms of indis-
 position were diarrhceal  affections,  attended with an  unusual degree
 of general prostration, which yielded readily to treatment, but were
 apt to recur.  In addition to this, the want  of  acclimation  and  the
 depressing influences just  mentioned, strongly predisposed them to
contract  febrile affections of typhoid type.   Thus,  out of about  50
individuals, including the members of the Japanese Commission and 
650            INTERNATIONAL EXHIBITION,  1876.
Bureau ol
Medical
Service.
Health of
English
residents.
Composition
of Centennial
Guard.
the Japanese  exhibitors, there were  9 cases  of typhoid and  typho-
malarial fever.  These cases were all treated  at the University Hos-
pital, and all  recovered.  They were  of a  rather mild  type,  with  a
peculiar absence of diarrhoea and of symptoms of nervous disturb-
ance.  Although the cases were not severe, it was further noted that
the convalescence was unusually slow and protracted.
  Among the English residents, of whom there were  36,—next in
number to the Japanese,—there was a moderate amount of diarrhoea,
but only two  cases of typhoid fever, both of which  recovered.  In
marked contrast to the  unhealthfulness of the Japanese  colony is to
be placed the excellent sanitary conditions of the  cottages  for  the
employees of  the British Commission.
  The most important question in  connection with  this part  of our
subject concerns the health of the Centennial Guard.  This body,
which  originally consisted of 1176 men, was selected with great care
as to their physical fitness.  It comprised representatives of twenty-
five States; the largest number from any one  being  608 from  Penn-
sylvania, of whom only 197 were from Philadelphia, so that over 80
per cent, of all were from country districts.  This fact has an impor-
tant bearing upon the liability to continued febrile affections conspicu-
ously displayed by the members of this force.  In regard to occupation,
about 50 per cent, of all had been  engaged, prior to their enrolment,
in in-door  pursuits  (as clerks, store-keepers, printers,  shoemakers,
etc.), which gave the worst possible preparation for the very exposing
and trying duties assigned to them as members of the Guard.  Indeed,
of the  50 per cent, who had previously been  engaged in what  we have
classed as out-door pursuits, as distinguished  from those which were
purely sedentary and in-door, there were several  large groups (such as
sailors, machinists, blacksmiths, etc.) who  were  not especially well-
fitted to bear protracted exposure to intense summer-heat.  An  exam-
ination of the  ages of the men enrolled, shows  that every year from
21 to  53 inclusive  was represented.  The  following  table  shows
the relative  number enrolled  for each period of five  years  from 21
onwards:
Age of the	From 21 to 25 years inclusive ...		223 meu
Guard.	" 26 to 30	" "	• 340 "
	" 31 to 35	" " . . . .	288 "
	" 36 to 40		211 «■
	" 4i to 45	" " . . . .	95 "
	" 46 to 50		12 "
	Over 50 years	af age .....	7 "
		Total.....	1176 "
 
REPORT OF THE DIRECTOR-GENERAL.          65 I
   Although the number of men actually enrolled  in the Guard was Bureau of
 [ 176, the daily average during the entire period of the Exhibition was Se^|"
 only 802.   The reduction in numbers was a gradual one, and, so far
 as is known, does not impair the general accuracy of the proportions
 we have given.   Attention has been called to the above  details about
 the  composition of the Guard, because it is evident that  they exerted
 a  large influence  upon the  high rate  of sickness  which afterwards
 prevailed among them.
   Owing to the  unusual  heat of the season, the uniform which was Un-formami
 adopted proved to be much too heavy and oppressive.   It must also barracks
 be observed that, in the  construction of the barracks in which the
 Guard were quartered, sufficient attention was not  paid to securing
 free ventilation or sufficient cubic feet of breathing space. It is prob-
 able that both the health and comfort of the Guard would have been
 better served by requiring the  men to  be within the grounds only
 while on  duty and allowing them to quarter  themselves outside.
   It was  inevitable, in consideration of the composition of the Guard, Sickness
 their arduous  duty,  and  the extreme heat  to which  they were ex- Guard.
 posed, that a considerable amount of sickness should have occurred
 among them.  This  showed  itself chiefly in the forms  of diarrhceal
 and  febrile affections and of solar exhaustion.  The diarrhoea was
 of a simple character and  amenable  to treatment, so that it  rarely
 necessitated the patient's  being off duty.  The forms of fever which
 presented  themselves were  simple intermittent, typho-malarial, and
 typhoid.  Nearly all cases of intermittent fever occurred among those
 who  had suffered previously  with the  same  affection within eighteen
 months.   In no instance did  it appear that the disease was contracted
 for the first time upon the Exhibition  grounds.   It is a well-known
 fact  that, in those who have once suffered from malaria, any cause of
 nervous  exhaustion, such as exposure to extremes of temperature or
 excessive exertion, may reproduce the symptoms of fever without there
 having been any fresh exposure to malarial  miasm.  When it is fur-
 ther  noted  that nine-tenths of the  cases of intermittent  fever among
 the Guard and other residents within the grounds occurred during the
 months of June, July, and August, it is clear  that there cannot be said
 to have been any marked degree of malaria about this locality.  During Absence of
 these three months, which were characterized by  extreme and dry malana
 heat, the climatic conditions were very unfavorable to the development
 of the malarial poison; while during the later months of the  Exhibi-
tion, including the period  when malaria is  usually most  prevalent, it
was found that not more than three or  four mild cases occurred.
  Of the other forms  of fever mentioned, typho-malarial and typhoid, 
652
INTERNATIONAL  EXHIBITION, 1S76.
Bureau of
Medical
Service.
Typhoid fever
among the
Guard.
Mortality
among the
Guard.
it is important to speak more at length, since the attention not only
of the medical profession but of the public was prominently directed
to this subject.  As, however, its chief interest concerned the health
of the public at  large more than that of the Guard, its consideration
will be found in  a later part of  this report.  (See pages 667-672.)
  It is difficult to determine accurately the  number of cases of typhoid
fever  occurring  among the Guard.   This  is chiefly because, on the
development of  any symptoms of a suspicious character, the patients
were in most instances removed to  their homes, and all future record
of the cases was lost.   It is certain, however, from the observation of
cases  of this character sent  to Philadelphia hospitals, that  many of
them  proved  to be simple diarrhoea, with  unusual prostration.  On
the whole, it may be said  that not more  than from  25  to  30 cases
of true  typhoid  or typho-malarial  fever occurred  among the Guard,
whose average  number  during the  months of May,  June, July, and
August, during which time all of the cases of fever originated, was 870.
When we recall  the conditions upon  which we  have dwelt as render-
ing the members of the Centennial Guard unusually liable to these
febrile affections, it becomes evident that the specific causes of typhoid
and typho-malarial fevers did not exist in any high degree of intensity
at the Exhibition grounds.
  The total number of deaths  known  to  have occurred among the
Guard is 8, from the following  causes:
Typhoid and typho-malarial fevers, after removal to their homes in other States
Typhoid and typho-malarial fevers, after removal to hospital
Organic disease of the heart, with rupture, after removal to hospital
Variola, after removal to hospital.........
Isolated cases
of smallpox
and measles.
  In connection with this latter case, it is interesting to observe that
it was developed in one of the Guard who was quartered in a crowded
barrack, and that it  was the only  case  of smallpox  that occurred.
In like manner, a single isolated case  of severe  measles presented
itself in a different barrack.
  In further confirmation of the view that the causes of the typhoid
fever which occurred were general in their character, and connected with
peculiar atmospheric conditions and with the peculiar composition of
the population resident within the grounds, there should be mentioned,
first, that the cases all occurred during the months of May, June, July,
and  August; and, secondly, that they were quite evenly distributed
over the extensive grounds;  thus there were cases among  the Guard
at the  barracks on George's Hill, among  the Japanese and  English at
their quarters on the Hill, among the guard at the Fifty-second Street 
REPORT OF THE DIRECTOR-GENERAL.
653
barracks, among those at the barracks at the eastern end of the Main Bureau of
Building, among those at the barracks at the northeastern extremity Se^,|^
of the grounds, and among those at the barracks immediately in front
of the Hospital, which was almost in the centre of the inclosure.   It
seems remarkable that at the barracks of Company G, which  was
situated  in Belmont  Ravine, between the Kansas  and  Colorado
Building and  Agricultural  Hall, there was not a single  case, as  this
location  seemed  to  present the  least favorable hygienic  conditions
of all.                                                            General health
   Apart from the diarrhoea and fevers which  have been spoken of,
the  general health of the Guard was good, the only ailments being
of a very trivial character.
   It may be stated, in conclusion, that, considering the great exposure
of the Guard, of the employees, and of the attaches of Foreign Com-
missions during the cold inclement weather of March and April, and
later during the  unprecedented heat of June, July, and August, their
health was better than could have been anticipated.                  Sanitary
   As yet there  have  been considered only those  sanitary questions tisitors'oth*
connected with the population resident within the grounds.  It  now Exhibition.
remains  to examine the interesting questions which concern the ex-
traordinary number of visitors who thronged  the  Exhibition during
the twenty-seven weeks of  its continuance.
   As already stated, during the first few weeks it was not generally
known  to visitors that provision  for  medical  relief had been  made. Medical
In view  of the frequent calls  subsequently  made  upon the Depart- Bureau shou,ci
                                                             1    be organized
ment, and  the valuable assistance rendered in many cases, it  seems early.
desirable that hereafter in  similar Exhibitions the Medical Bureau
should be organized at a very early date, and that the attention of the
public should be called to it in the clearest possible manner.
   On the opening day, May 10, although there were  186,672 visitors,
there would seem to have been no serious accidents, since but 5 cases „ ,.   .
                                                 '          •>      lotal number
applied at the Medical Department,  3 of which were slight injuries of cases
and  2 were cases of exhaustion.  It  is probable, however, that there Hospitai.
were many other similar cases which  were  removed directly to their
homes, and of which consequently no record has  been kept.  From
that  date to the closing day (159 days in all), 6463  cases were treated,
making a daily average of about 41.
  The following analysis of the actual  residences of the cases, although
of course not  in any way proving that the same proportions held  in
regard to the entire number of visitors, is of interest: 
654
INTERNATIONAL EXHIBITION, 1876.
Bureau of
Medical
Service.
Residences of
patients.
Sex ot
patients
Ages o\
patients.
			I.—RESIDENCES OF P		\TIENTS.		
Austria . 2 | West Indies					1 Nebraska .		7
Bavaria			1 1 Alabama		14	Nevada	2
Belgium			4 Arkansas		7	North Carolina .	14
Bohemia			1	California .	32	New Hampshire	66
Brazil .			3	Colorado	8	New Jersey	249
Canada			68	Connecticut	292	New York	1268
Cuba .			1	District of Columbia	65	Ohio	3'«
England			55	Delaware .	42	Oregon	1
France.			23	Florida	9	Pennsylvania	2104
Germany			21	Georgia	18	Rhode Island .	58
Ireland			11	Illinois	116	South Carolina .	11
Italy .			4	Indiana	97	Tennessee	'5
Japan .			32	Iowa .	64	Texas	n
Jerusalem			1	Kansas	21	Vermont .	79
Norway			1	Kentucky .	20	Virginia .	58
Nova Scotia			11	Louisiana .	6	Wisconsin	48
Poland			1	Massachusetts	495	Not known	165
Portugal Prussia.			1 4	Maryland . Maine	139 42	Total .	6463
Russia .			13	Michigan	163	United States .	6016
Syria .			2	Minnesota .	7	Foreign countries	282
Scotland			2	Mississippi .	10 | Not known		165
Sweden			12	Missouri	33		
Turkey			7	Montana	1	Total .	6463
  It is  seen from  the  above table that 93 per cent,  of  all persons
treated were residents of the United States, representing 39 States and
Territories; while but 4.36 per cent, of all were from foreign countries.
Of  those from the United States, 35 per cent, were from Pennsylvania,
21  per  cent, from  New York, 7.6 per cent, from  Massachusetts, 4.9
per cent, from Ohio, 4.5 per cent, from Connecticut, and 3.8 per cent.
from  New Jersey.   Of those from foreign countries, 55  were from
England, 32 from Japan, 23 from  France, and  21 from Germany.
  Of the  total number of cases (6463),  1799 were females and 4664
were males.
                      II.—AGES OF PATIENTS.
Ages.	
Undei	1 year
I to	5 years
5 ^	10 "
10 to	20 "
20 to	40 "
40 to	60 "
60 to	80 "
80 to	100 "
Not given .	
Total
Males.	Females
5	I
•7	9
51	26
449	222
2348	759
88S	285
>4S	38
1	2
763	457
4664
1799
  The oldest patients included in the above table were one man aged
81, and two women aged respectively 95 and 96 years;  while, on the
other hand, the youngest patients were 2 and 4 weeks respectively. 
REPORT OF  THE  DIRECTOR-GENERAL.
655
   The following tables present a summary of the principal  causes of  Bureau of
                   ...          ,   T, . ., .  .     ,   .    ,                    Medical
sickness among the visitors to the Exhibition during the twenty-seven  Service
weeks of its continuance :
                            III.—MEDICAL  CASES.
   Respiratory and Circulatory Diseases.
Asthma
Hay asthma
Bronchitis
Haemoptysis
Organic disease of heart
Palpitation of heart .     .     .    .    13
Miscellaneous  .....    66

  Total......246
           Digestive Diseases.
Cholera infantum   ....     1
Cholera morbus    .     .     .    .   151
Diarrhoea.     .....  1686
Dysentery     .    .     .     .     .    19
Indigestion    .....   499
Cramps  .     .....   487
Constipation   .    .     .     .     .215
Miscellaneous  .....   141

  Total......3199
            Nervous  Diseases.
Apoplexy......2
Headache.....356
Neuralgia (including toothache and
  earache)     .....   364
Epilepsy......28
Hysteria......50
Insanity  ......     2
  9
  2
135
 13
Vertigo
Meniere's disease
Miscellaneous .
Total
Fevers.
Simple fever  .
Intermittent fever
Remittent    "
Typhoid      "

  Total  ....

             Effects of Heat.
Heat exhaustion
Thermal fever .
Sun-stroke

  Total  ....
         Effects of Over-exertion.
Debility and exhaustion  .
Faintness and syncope

  Total  ....

Intemperance  .
Miscellaneous medical  cases
Wounds
 Bites and stings
 Contused wounds
 Incised wounds
 Lacerated wounds
 Gunshot wounds
 Punctured wounds

  Total  .
         Accidents
 Scalds
 Burns
Contusions
Dislocations
Sprains
Fractures .
and Injuries
                Total medical cases

IV.—SURGICAL  CASES.
              Fractured larynx
          25  Concussions
          56  Foreign body in eye .
          73  Foreign body in ear .
         100  Foreign body in throat
           3  Hernia
          11  Hernia (strangulated)

         268    Total  .
              Miscellaneous surgical cases
'4
12
96
 4
64
12
  Total surgical cases

Medical cases  .
Surgical cases  .

  Total  .
55	Analysis cf
1	medical and
7	surgical d-c
	treated at th
865	Hospital.
27	
212	
5	
6	
250


 29
 10
  2

 41
266
 44
  10
 596

55'9
   1
   4
 192
   1
   4
   4
   6

 414
 262

 944

55'9
 944
6463 
          6^6             INTERNATIONAL EXHIBITION, 1876.

Bureau of      About one-fourth of these cases were of such severity as to require
'■evvicc'     admission  to  the Hospital  wards, while the remainder were capable
          of being immediately  relieved.  In the vast majority of cases the pa-
          tients admitted to the wards recovered  so speedily as  to be able to
          return home without aid.   In not more than 35 instances during the
          entire season  did the  patients continue so ill as to make it necessary
          to have  them conveyed to  their homes in the ambulance when the
          Hospital was  closed at nightfall.  In  no instance was it necessary to
          deviate  from  the rule of the Department, that no case of sickness
          should remain in the Hospital building over night.
            It  will be  observed that  3199, or  more than one-half the entire
          number  of medical cases, were  connected with the digestive organs.
          Although  the majority of these originated at the Exhibition, a con-
          siderable number were cases of longer standing.  It  is important to
chronic ca-es. note  this,  not only in connection with this class of affections, but
          with  all the other classes,  since, in reality, a considerable proportion
          of the cases were in no way chargeable to the visit to the  Exhibition.
          Thus, so soon as it became generally  known  that gratuitous  medical
          advice could be had, a large number of persons with chronic affections
          of a  medical  or surgical  character  applied  at the  Department for
          relief.   It was  thought expedient  not to refuse such applications,
          although they were recognized as an abuse of the Medical Depart-
          ment, which was intended solely for the relief of cases of emergency.
c .uses of    ^he  great majority of the cases of digestive disturbance were directly
disc.scsof   traceable  to  excesses or   indiscretions in eating; and, when  it  is
org"!C    remembered that such vast  numbers of persons, collected from  all
          classes of society and accustomed to all varieties of  occupation and
          climate, were exposed to the combined influence of excessive fatigue
          and  excitement, of extreme heat and  of irregular diet and hours of
          eating, it is truly remarkable that sickness from these causes was not
          vastly more common.  It  should also be observed that in supplying
          the enormous demand for certain articles of food it must occasionally
          have happened that supplies of inferior quality were used.  This was
          particularly the case with regard to articles of such perishable character
          and of such general consumption as milk, meat, eggs, etc.   A forcible
          illustration of this was given on the 11th of  July, when no less than
          26 patients with severe cholera morbus were  admitted to the hospital
          in the course of an hour and a half, all of whom had been taken ill soon
          after partaking of a lunch of pie and milk at one of the  restaurants.
          It cannot be doubted  that this violent outbreak was dependent  upon
          some subtle  organic  change in one  of the articles mentioned,  prob-
          ably the milk, by which it acquired highly irritant poisonous qualities. 
REPORT OF THE DIRECTOR-GENERAL.         657
Probably, however, sickness was less frequently caused by such spoiled Bureau of
or tainted provisions than by excessive fatigue in very hot weather, Service
by the copious  use  of iced drinks of all kinds while  the  body was
greatly overheated, and by the consumption of indigestible articles of
food when in a state of great physical exhaustion.  Vast  numbers of
those who visited  the Exhibition did so at great personal  and pecu-
niary sacrifice.   Every effort was made, therefore, to condense their Conditions
visit to all  parts  of the Exhibition into the shortest  possible  time, Jcknlsson
and it is difficult to conceive of the excessive fatigue and exhaustion part of visitors.
involved in this attempt.   A large proportion of the visitors were
women or young  persons entirely unfitted for enduring the physical
fatigue of a  succession of long days, spent on foot, in constant  motion,
in the midst of  vast throngs of  people, and with the mind  overtaxed
with the ever-changing novelties and attractions of the scene.  Very
many of the visitors came from  localities  whose climates  differed
widely from that  which they here found.   They  abruptly changed
all  their habits of living,  and,  in  too  many instances, neglected the
hygienic rules which are essential to health.
   During the later months of the  Exhibition, there were unfavorable Drinking-
            1   1  ■        1 .   1      •.    r .i    1 •  1  •             water did no*
reports circulated  in regard to  the purity of the drinking-water sup- actinanyway
plied  to  the  Exhibition grounds  and the  neighboring portion of as a cause of
West  Philadelphia; but careful investigation showed that  they were
unfounded.   The water was drawn  from the Schuylkill River  at
a  point  opposite  the Exhibition  grounds.   It  is  true  that, in the
extreme haste with which many of the small  buildings within the
inclosure were  erected, the rules  issued on this subject  were dis-
obeyed in a few  instances, and wells were constructed having con-
nection with one or the other of the two small streams which flowed
through the grounds and emptied into  the  river not far from the
above point.  In  every case, however, this was  soon detected and
instantly  corrected.  Any contamination of the  water supply from
such a source could only have occurred during  the first  few  days of
the Exhibition.   As a  matter  of  fact, no sickness occurred during
this period.   Careful analyses were made at short intervals by Dr.
C. M.  Cresson, which showed that  the purity of the water taken from
this point of the Schuylkill was fully up to the  standard of previous
years as well as to that of the water supply of  neighboring cities.
The most conclusive evidence, however, on this point is to be drawn
from the actual experience of the large number of persons who drank
the water freely during  the entire  period of  the Exhibition, but who
were not exposed  to the various causes of sickness which influenced
the Guard and visitors.   In no single  instance did any sickness of a
                                42 
658
INTERNATIONAL  EXHIBITION, 187b.
Bureau of
Medical
F.vhibition
grounds and
vicinity free
from any
special cause
of disease.
Conclusions as
to sanitary
conditions of
grounds.
 typhoid or diarrhoeal character  occur.   We have already seen that
 the amount of typhoid fever among the Guard was small, taking into
 consideration the peculiar composition of that body, and, further, that
 the cases which occurred took  place within a limited period, marked
 by unusual  meteorological  conditions, while  the water supply re-
 mained unchanged.   Finally, we have seen that the cases of diarrhoea
 occurring among the Guard were light in character and readily amen-
 able to treatment, though all the time the patients were using large
 quantities of this drinking-water.
   As a further evidence of the fact  that  no special cause of typhoid
 fever existed at the Exhibition grounds or in their vicinity, it may be
 stated  that in  the Twenty-fourth Ward, which  embraces almost the
 whole  of Fairmount Park and all of the  adjoining portion of the city,
 the total number of deaths from typhoid fever for the entire year was
 44, of  which 30 occurred between May 10 and November 10.  The
 population of this ward in 1875 was 41,310, but during the Exhibition
 period it may be safely estimated—in consideration of the large tem-
 porary hotels, all of  which were included in this ward, and the  enor-
 mous number of boarding-houses and private residences which were
 constructed for the occasion—that the population was at least 75,000,
 which  gives a rate of mortality per 1000 from typhoid fever during
 this period of only .4.
   In conclusion, we  may state, as the result of careful study of this
 question of the sanitary condition of the Exhibition grounds,  in re-
 gard to which so much was said at the time:
   First, that there is no evidence to show that  any special cause of
 sickness existed there.
   Second.  That with regard  to the  supply of drinking-water in par-
 ticular, there is no evidence to show  that its use predisposed either to
 typhoid fever or to diarrhoeal affections.
   Third. That the sickness occurring among the Guard and employees
 resident within the  grounds  was  due to  peculiar causes above con-
 sidered, which were in no way connected with the sanitary condition
 of the  grounds.
   Fourth.  That the sickness  occurring among the visitors, which was
 actually dependent upon their visit to the Exhibition, was due exclu-
 sively to the effects of over-fatigue, indiscretions in eating and drink-
 ing, undue exposure to great heat or to inclement weather, etc.
   It remains now in  connection with the record of sickness  among
 the visitors to allude to a few peculiarities.
   A considerable number of cases showed, as would  have been ex-
pected,  the injurious effects  of  the  extreme  heat.   Doubtless, this 
REPORT OF THE DIRECTOR-GENERAL.          659
 cause aided in producing many of the cases classed as simple exhaus- Bureau of
 tion.  The cases, however, in  which  sickness was directly traced to SerV|ce
 the  effect of heat were 41 in number, of which 32 occurred  between
 the  25th of June  and the 22d of July,  during which four weeks the
 average  temperature  was  8i^°F.   The  majority of cases,  29 in
 number, presented the ordinary symptoms of nervous exhaustion fol- Direct effects
 lowing upon  exposure either  to the  direct rays of  the sun or to a
 very high degree of temperature within-doors.   In the 10  cases re-
 corded as thermal fever, the  symptoms were much more severe.  The
 patients were still  conscious, or in some cases delirious; there was
 intense heat of surface, congestion of the  eyes, deep flushing of the
 face, and great rapidity of the pulse.   These  cases were treated by
 immersion in  baths of  ice-water,  and  promptly recovered.   The 2
 cases recorded as sun-stroke were characterized by sudden and alarm-
 ing  development of temperature, the patients almost  instantly passing
 into a state of coma with stertorous respiration, with livid congestion
 of the  face and surface, and with extremely small  and  rapid  pulse.
 They were stripped and were then vigorously rubbed with pieces of
 ice  until a marked reduction of temperature took  place.   As this
 occurred, consciousness  returned, followed in  both  cases  by rapid
 recovery.
   In regard to the class of nervous diseases, there are several points Nervous
 of interest to be noted.  Thus, there were but two cases of apoplexy,
 one of which  occurred  in an  intemperate  man, and proved almost
 immediately fatal, while the other was a mild  attack,  probably of
 localized apoplectiform congestion  of  the brain, occurring in  a young
 man engaged  as  a chair-pusher,  an occupation  which involved ex-
 hausting effort and prolonged exposure  to the sun.   There were only
 28 cases of epilepsy treated  at the  hospital among 9,910,966 visitors
 to the Exhibition.   It is of course highly probable  that  very many
 more epileptics were included in this number who were not  so unfor-
 tunate as to have  an accession of their terrible  malady while within
 the  grounds.   The  cases recorded  as vertigo were almost exclusively
 dependent upon indigestion.  As a matter of purely  medical interest,
 it may be mentioned that a single case of that rare affection, Meniere's
 disease or labyrinthine vertigo, presented itself at the  Department.
   The only remark  to be made in connection with the class of respi- Respiratory
 ratory and circulatory diseases  is to call attention to the very small circulatory
 number of cases, only 21, who were attacked with disturbance of the diseases
 heart, either due to functional  or  organic  disease; as well as to the
very small number of cases  of haemoptysis, only 13, which occurred
among  the enormous number of visitors.  We have  already re- 
66o
INTERNATIONAL  EXHIBITION, 1876.
Bureau of
Medical
Service.


Absence of
intoxication.
Deaths within
the grounds.
Surgical cases.
Remarkable
absence ol
accidents.
 marked that  the  large number of cases of digestive disorders, 3199,
 were nearly all attributable to excesses or indiscretions in  eating or
 drinking, with the exception of cases of a chronic character.
   In illustration of the class of persons  who visited the Exhibition, it
 is to be observed that but 10 cases  of  intoxication were brought to
 the  hospital for treatment.   It was  anticipated that a considerable
 number of cases  of abortion or miscarriage would occur in conse-
 quence  of  the  excessive  exertions  and fatigue  incurred  by  many
 visitors  to  the Exhibition.  In  but one case, however, did abortion
 result;  and in one other miscarriage  was threatened, but was averted
 by rest and the  use of opium.
   There were but 4  deaths within  the grounds  during the entire
 period of the  Exhibition.  Of these,  2 occurred from organic disease
 of the heart and 2 from apoplexy.
   The surgical cases, 944  in number, were for the most part of minor
 severity.  It is a striking illustration of the good order which prevailed
 among the vast crowds which daily assembled in the grounds that there
 was  not a single case of injury resulting  from personal violence. This
 was  especially remarkable  on those days when some particular attrac-
 tion  drew unusually large  numbers of visitors.  Yet even on " Penn-
 sylvania day," when over a quarter of a million persons were  gathered
 within the grounds, most of whom remained until  long after  nightfall,
 so perfect was the good temper of the crowd, so entirely capable were
 they of taking care of themselves, and so careful to respect each other,
 that, although no special precautions were taken and no additional con-
 stabulary was employed, the occasion was entirely unmarked by any
 unusual  accident.   No quarrel occurred, and no woman or child was
 crushed  or  trampled upon.  The passenger railway which traversed
 the grounds carried 68,273 persons on  that day; and, although  the
 crowded trains frequently seemed to  literally plow their way through
 the dense masses which lined the tracks, there was not a single acci-
 dent.  It may be questioned whether any festival, equally remarkable
 in all respects, has ever o'ccurred.  It is also noteworthy, when  the
 enormous amount of machinery in motion, and the  throngs of curious
 visitors  constantly surrounding each machine are considered, that  not
 a single accident happened, with the exception of a few trifling contu-
 sions and lacerations occurring among  the  workmen.  There were
 3,784,142 passengers in all carried by  the Narrow-Gauge  Railway
 Company, without the occurrence of any accidents.
  For the entire period of  the Exhibition the ratio  of cases of sick-
ness  among the visitors was I in every 1533.   The greatest number
of patients treated in one  day was 114,  on September 28, " Pennsy^- 
REPORT OF  THE DIRECTOR-GENERAL.
661
vania Day," when there were 274,919  visitors, thus giving  1  patient Bureau of
in every 2411 ; while  on  the 20th  of July there were only 25,936^)^
visitors, and 58 cases of sickness, or 1 in every 447, the highest per-
centage occurring during the Exhibition.
  The following  table shows the  number of patients treated at the
Hospital, and the proportion borne to the total number of visitors on
the days when  the attendance at the Exhibition was  greatest.   The
mean temperature has also been placed in connection with the  other
data:
TABLE  V.
  Number of  Number of Pa-
  Visitors to   tients treated
May 10, Opening Day
July 4.....
August 24, New Jersey Day
September 7, Connecticut Day  .
September 14, Massachusetts Day
September 21, New York Day  .
September 28, Pennsylvania Day
October 5, Rhode Island Day  .
October 12, New Hampshire Day
October 19, Delaware and Maryland
    Day.....
October 26, Ohio Day
October 27, Vermont Day .
November 10, Closing Day
the Exhi-
 bition.
186,672
 56,494^
 67,052
 75.044
 97,868
 134,588
 274,919
 100,946
 "5.422

 176,407
 i35,66i
 108,080
 121,721
at the Hos-
pital.
   5
  48
  60
  59
  80
  60
  114
  48
  53

  7'
  73
  53
  3'
Ratio.
I in
1 in
1 in
1 in
1 in
I in
1 in
1 in
1 in
37,334
 1,177
 1,117
 1,272
 1,222
 2,243
 2,411
 2,103
 2,177
1 in 2,484
1 in 1,852
1 in 2,039
I in 3,926
       Amount of
       sickness in
 .,    proportion to
 Mean     .
Tempera- number of
ture, Fah. visitors.
 56.7
 82.5
 73-7
 63.0
 68.2
 61.7
 56.2
 58.5
 45-°

 537
 45-5
 43-7
 39-7
   The opening day may be disregarded  in this respect for the reasons
 already given.   With reference to the other days, it will be observed
 that so  long as the average  temperature was  moderate, say between
 400 and 6o°, the sickness among the visitors was  apparently not in-
 fluenced by it, but varied within  certain  limits from  other  causes.
 When, however, the average temperature was  materially above 6o°,
 it was found that the  proportion of sickness increased  considerably.
 As the temperature was the  chief agent in influencing public health
 during-  the  Exhibition, it will be interesting to subject it  to  a more
      *?                       ...                                Influence
 careful study.  In order to facilitate this, Charts Nos.  1 and 2 have been of high
 prepared.   The first feature which is apparent from these is the exces- temPerature-
 sive temperature that prevailed during the thirteen weeks of June, July,
 and August.  During this entire period  the average weekly tempera-
 ture was continuously above 700, and during the four weeks  ending
July 22, the average weekly temperature was 8t^° Fah.  The effects
of this protracted  heat were  aggravated by the dry character of the
season.  The influence of  the elevated temperature  upon the amount 
662
INTERNATIONAL  EXHIBITION, 1S76.
Bureau of    and character of mortality in the city at large is very apparent, and
ServL.     w'^ De carefully discussed  later on.  We would now ask attention
          to  its influence upon the admission.^  to the Exhibition and  upon
          the  amount of sickness among the visitors.   It will be seen  that
          during the  first 5 weeks of the  Exhibition, up to June 10, there was
          a steady increase in the total weekly admissions to  the  grounds, so
          that for the week ending with the above date they numbered 233,406.
          At this time it was confidently expected that, as the  traveling season
          was about  to begin, there would  be a rapid rise in  the attendance.
          Unfortunately, however, the  heated  term, which was  destined to be
influence     so iongr and so intense, began at that date. In consequence, undoubt-
ofhigh            fa               '  fc>                        1     >
temperature   edly, of the reports concerning the  heat which were quickly circu-
on Remissions  iatecj  tile  attendance, instead of  increasing, immediately showed a
and on amount                                        °             J
of sickness,   falling off.   In  the  week ending July 1 the  number had fallen to
          210,108;  average weekly temperature, 81 °.  The total  for the week
          ensuing, average temperature being 8o°, was brought up to 315,853
          by  the large number  of visitors attracted by the ceremonies of the
          4th of July; but in  the following  week, with an average temperature
          of  830, the total fell to 174.7925^;  and in  the week after, with an
          average temperature of 8o°,it continued to fall, and reached the num-
          ber 166,744.  At this point  a break in the continued heat occurred,
          and the attendance  instantly began to rise, but it was not until the
          15th  week of the Exhibition that the number of visitors had attained
          the point where it stood in the 5th week.  From this point the attend-
          ance  rapidly rose, and was no longer influenced by the  temperature,
          which continued moderate  until the close  of the Exhibition.  The
          irregularities in the curve showing  admissions (represented by the
          dotted black line) were chiefly, if not entirely, dependent upon the
          occurrence  of  certain days of particular interest.  While undoubt-
          edly  the total  admissions  to the Exhibition  were  seriously dimin-
          ished  in consequence of the extreme heat which raged during the
          month of July and parts of June  and August, it is a matter of con-
          gratulation  that large numbers of  strangers did not visit Philadelphia
          during that time.  It would have been impossible for the vast throngs
          which crowded the  grounds during the  latter part of the season to
          have visited them  during  the heated  term  without a lamentable
          amount of  sickness  resulting.   The effects of the  heat upon the
          general attendance  at the Hospital  are clearly shown by following
          the dotted  red  line  in Chart No. 2.   The fact  that after the marked
          fall in this  attendance which followed the break  in  the heated term
          the number of cases again began to increase  in  the  15th week, and
          continued quite large  during the rest of the season, was entirely due 
REPORT OF THE DIRECTOR-GENERAL.
663
to the great and progressive increase in the general admissions to the Bureau of
                                                                   Medical
                                                                   Service.
grounds, which began at that date.  Although this effect is shown in
the general attendance at the Hospital, it is far more clearly displayed
in regard to diarrhoeal affections (see dotted yellow line in Chart No.
3) and  the class of cases showing exhaustion in its various forms.
(See dotted yellow line in Chart No. 2.)
   We invite attention, in the next place, to the sanitary statistics of the Sanitary
city of Philadelphia at large during the period of the Exhibition.  In Philadelphia
endeavoring to estimate the effect produced upon the health of the com-
munity by the sudden introduction of vast numbers of unacclimated
strangers, it is necessary to bear in mind the peculiarities of the season
and the very great differences which occur, without appreciable cause,
in  the  mortality  from some  of the principal diseases  in different
years.
   It is also highly important to determine  as  closely as  possible the Estimated
movement of the population of the city during this period.  It is need- p°Pulal10"01
                 11                J      °     l                  city during
less to  say that, for the following reasons, this can be done with only Exhibition
approximative accuracy.  In  the  first place, the floating portion of Penod-
the population was directly absorbed into and blended with the resi-
dent population in a most remarkable manner.  In other cities, when
an occasion draws a large concourse of visitors,  the additional num-
bers are accommodated chiefly in hotels and boarding-houses.  Of
course  a  considerable number would also be  received as guests  into
private families, but these would form but a very  small proportion of
the whole. On the other hand, although  the hotel accommodation
in Philadelphia was very largely increased  in anticipation of the Ex-
hibition, and although many additional boarding-houses were opened,
the  great bulk of the floating population was quartered in private
houses.   This was partly  the result of the operations of the Centen-
nial Boarding-House  Agency, which enabled all housekeepers, who
so desired, to receive  as many lodgers as they could accommodate;
but it was chiefly  due to a system  of hospitality so lavish and so uni-
versal that it  has probably never  before been equaled.   The almost
unlimited  extent to which this reception of guests and  lodgers was
carried can only be understood by  recalling the fact that Philadelphia,
with a  population estimated in  the early  part of 1876  at 817,488,
contained, in addition to other kinds of buildings, over 143,000 houses
occupied by families, thus  giving an  average of less than six persons
to each residence.  The second source of difficulty in estimating the
total population of the city lay in  the frequent and extreme fluctua-
tions which occurred in it.  In the following statements, the ordinary
floating population necessarily incident to the daily life of a great 
664
INTERNATIONAL  EXHIBITION, 1876.
Bureau of
Medical
Service.
Fluctuations
in number of
strangers In
city.
Sources of
difficulty in
estimating
health of city.
Sickness
among
visitors to
Exhibition
after their
return home.
city is of course excluded.  Bearing in mind the result of the census
above  given, it  may be  safely estimated  that from May 10 to June
25, the beginning of the period of intense heat, the daily number of
strangers in  the city was from 30,000 to 50,000.   From June 25 to
August 10 the number  must  have  fallen off considerably, and prob-
ably ranged from  15,000 to 25,000 per diem.  After  August I the
number steadily and rapidly increased, so that during the last three
months of the Exhibition  it ranged  from 50,000 to 200,000.  It will
be seen later that these fluctuations in the population bear an interest-
ing relation to the variation in the amount of certain diseases.   In
order  to serve  as  a basis of calculation it is necessary  to  decide
upon a figure as representing the average population during the entire
Exhibition period.   After much reflection it appears proper to adopt
the figure 900,000 as being unquestionably a safe and rather low esti-
mate, and we shall accordingly use this as our basis in computing and
comparing all ratios of sickness, mortality, etc.  There are, however,
two sources of difficulty met with in attempting to give any definite
idea of the health of Philadelphia during this particular period.  The
first of these is incidental to all such calculations, and depends upon
the fact that the records of the Board of Health give only the number
of cases of death  from various causes, and  that  no means exist for
obtaining the actual number of cases of  such sickness which  have
occurred.  In regard to  dangerous affections, where the rate of mor-
tality is considerable and more or less definite, it  is possible to make
an approximative calculation of the total number of cases which have
occurred, based upon the  number  of deaths.   But  in the case of
comparatively non-fatal  affections, it is obviously impossible to apply
any such rule.  The other source  of difficulty lies in the fact  that
much  of the sickness which occurred was   among visitors, who in
many  instances, as soon as  attacked, returned to their  homes.  It
is of course impossible  to estimate what amount of  mortality may
have  thus  occurred in  different parts of the country from sickness
actually contracted in  Philadelphia.  So much  discussion  of  this
question has  taken place in  many quarters, both at the  time  and
since  the close of the Exhibition, and  so many statements were
made which we are compelled to regard  as  greatly exaggerated, that
it seems necessary to  consider it somewhat in detail.  It cannot be
doubted that, owing to the unusually severe character of the season,
and  perhaps to peculiar atmospheric conditions which we cannot ap-
preciate, there existed  a strong  tendency to diarrhoeal and typhoid
affections over a large section of the country.  During the six months
with which  we are chiefly concerned the above diseases are the  only 
REPORT OF THE DIRECTOR-GENERAL.
665
 ones which caused  any considerable  amount of mortality, and we Bureau of
 shall therefore devote  particular care to  their consideration.   In SerV|ce.
 speaking of the sickness  among the visitors to the Exhibition, we
 have already alluded to the numerous causes which predisposed them
 to diarrhoeal and febrile affections.  We beg here to refer to what was
 said at that point (see pages 654-5), because we are convinced, from
 careful observation and reflection, that there existed no special condi-
 tions in the city, either at the Exhibition grounds or elsewhere, whether
 in the form of imperfect drainage, impure drinking-water, or any other
 special local feature, which were calculated  to induce sickness.  We sickness
 have endeavored to show that, on the contrary, the  great proportion circumstances
 of sickness which did occur among the visitors to the Exhibition was under which
 dependent  upon the circumstances of their visit, such as  long and was visited.
 hurried journeys, excessive fatigue while at the grounds, indiscretions
 in eating and drinking, etc.
   Not  only indeed  did  large numbers  of persons  arrive in the city
 thus predisposed to contract sickness from any cause, but we became
 acquainted with the fact  that  in many cases  sickness  was actually
 contracted and had even developed itself before their arrival here.  It
 is of course impossible to estimate the number of such cases, but from
 our personal knowledge of several deaths and of not a  few cases of
 serious sickness, occurring  in  this manner, we  infer that  the  total
 must have been large.   Indeed, when we consider the full force of
 these influences, and the vast numbers upon whom they operated, it
 appears remarkable that the mortality statistics were not more seriously
 affected  than they were.  Thus, we find that out of  10,294 deaths in
 Philadelphia from  all causes during the six months from May 10 to
 November io, only 1333, or 11.8 per cent., were from diarrhceal affec-
 tions.   Of this number  no less than  1232 deaths occurred among
 children under 5 years of  age, leaving only  101 deaths from all  diar-
 rhceal affections during the entire Exhibition  period among adults
 and children above 5 years of age.
  In comparing this  with  the mortality from the same causes during No excessive
 the corresponding period of previous years,  it is found that it is even diarTceain
 below the average.   Thus, while during  the hot months of 1876, from *ecity.
 May to November  inclusive, the mortality from diarrhceal affections
 among children under 5  years of age was  1.38 per 1000 of the  total
 living population, during the 7 years from 1862 to 1868  inclusive the
 rate was 1.78 per 1000.  In regard to diarrhceal affections occurring
among adults, the record of 1876 shows no  less favorable  results  in
comparison with previous years.  To show how entirely these dis-
eases were under the  influence of high temperature, we refer to Chart 
666
INTERNATIONAL EXHIBITION, 1876.
Bureau of
Medical
Service.
No. 3.   By following the yellow line it will be seen that, after the tem-
perature had  continued above 700 for a  short  time, the  mortality
from diarrhceal affections began to increase;  and that, from the close
of June, when the mean weekly temperature reached 8o°, it continued
diarrhoea.
Marked
influence of
m'ortanty from to increase with frightful rapidity for 3 weeks, when a decrease in tem-
          perature was accompanied by a fall in the mortality; and finally that,
          during the last week of July and the first week of August, when the
          mean temperature was 710 and 700, this fall continued at a rapid rate.
          A rise in weekly temperature to 780 and y6°, during the middle of
          August, was accompanied with a moderate  rise in the mortality from
          diarrhceal affections, quickly followed, however, by a still more de-
          cided and  persistent fall, so  that  after the first of  September the
          number of deaths from that cause  was comparatively small.  It has
          already been shown that scarcely any part of this mortality  was con-
          nected with the  influx of visitors  to the  city; and this is  further
          proved by the fact that from  the very time, September 1, when the
          mortality  rapidly and  finally  fell, the attendance  at  the  Exhibition
          grounds rapidly and  steadily rose.  The number of cases of diarrhceal
          affections treated  at the Medical Department, and due exclusively to
          such causes as indiscretions  in  eating and drinking, followed with
          considerable closeness the fluctuations in  the weekly attendance at
          the Exhibition.   As  corroborating  the truth of what has more than
          once been stated  with regard to the sanitary advantages of  Philadel-
          phia  we ask attention to the following  table, which shows the relative
          mortality from diarrhceal affections during  1876 in Philadelphia and
          some other large  American cities:
Mortality from
diarrhoea in
large cities.
1876.	Philadelphia.	New York.	Brooklyn.	Baltimore.	Chicago.
	825.594 1.417 1.66	1,054,000 3,782 3-5°	506,233 1.542 304	355,<»o 866 2.44	420,000 954 2.28
Mortality from diarrhceal affections. Death-rate from diarrhceal affections					
					
Mortality from
typhoid fever.
  Next to diarrhoeal affections, which caused a mortality of 1333 out
of 2485 deaths from all zymotic diseases during the Exhibition period,
typhoid fever was more fatal than any other disease of this class. No
less than 450 deaths are recorded as having occurred during the six
months from  this affection; and taking  the entire  year 1876, the
total number of deaths from this cause was  761.
  We  have  already expressed our belief that in a not inconsiderable
portion of these  cases,  inflammatory  diarrhoeas of  a typhoid type
were reported as cases of true typhoid  fever.   But this does not in- 
REPORT OF THE DIRECTOR-GENERAL.          667
terfere with the fact that  during the entire  year 1876  there was a Bureau of
much larger amount of typhoid fever in this  city than is usual.   In Se*vjc*
order to clearly show this it  is only necessary to give the following
table of the annual mortality from typhoid fever for the past 16 years,
with the annual death-rate per 1000 living:
Year........................... Population in thou-	1861 565 281 •49	1862 565 654 i«5	1863 565 486 ■85	1864 565 648 1.14	1865 565 773 1.36	1866 674 381 •56	1867 674 367 ■54	1868 674 395 .58	1869 674 373 ■55	1870 674 409 .60	1871 674 3'3 •47	.872 725 369 .50	1873 750 382 .50	1874 775 472 .60	1875 800 420 .52	1876 825 760 .91
Total mortality from																
Annual death-rate per																
																
Excessive
mortality from
typhoid fever
in 1876.
   During the Exhibition period the population may be estimated at
 900,000, and  this, with  a  mortality during those  six months of 450
 from typhoid fever, gives a rate of annual mortality from  this cause
 of 1  per  1000.   It  will be seen, on  examining  this table, that the
 annual death-rate per 1000 from typhoid fever during last year was
 exceeded  during the  years 1862, 1864, and 1865, while it was very
 closely approached  in 1863.  In considering the causes which led to
 the  high  rate of mortality from this  disease during the latter years,
 it will be  found that it was connected with the large number of sol-
 diers who were quartered  in and around the city.  So, too, in con-
 sidering the sudden  increase in typhoid fever that occurred during the
 year 1876, the most important cause which suggests itself is the enor-
 mous influx of unacclimated visitors during the Exhibition period. It
 has  long been known, in connection with typhoid fever, that none are
 so likely to be attacked as the residents of small towns or rural dis-
 tricts, when visiting large  cities to whose climate and  conditions of
 life they are unaccustomed.  This is undoubtedly because such persons
 are much more susceptible than the permanent residents to the causes
 of typhoid fever, even though existing only in the moderate degree
 which is too often found  in large cities.  The truth  of this may be
 realized from  the fact  that  during the Exhibition period in 1876 the
 number of deaths from typhoid fever was 450, as  contrasted with 207
 deaths from this cause during  the corresponding period of 1875.
   That this increase was due to the vast influx of unacclimated visi-
 tors, and not to any  special prevalence of the causes of  typhoid fever
 during that period, may be inferred from the fact that in those hospi-
 tals which received almost exclusively patients from among the poorer
 classes resident in the  city, the number of cases of typhoid and typho-
 malarial fevers treated between May 1 and November 15, 1875, was 49,
while during the corresponding months of 1876 the number was only
This excess
due to influx of
unacclimated
visitors,
Cases of fevei
treated at
hospitals. 
668            INTERNATIONAL EXHIBITION, 1876.
Bureau of
Medical
Service.
Ratio of deaths
from typhoid
fever to
number of
visitors.
28.  On the other hand,  in  those  hospitals which receive  patients
chiefly of a better  class, and to which, consequently, strangers who
may be taken sick while on a visit to the city are frequently admitted,
the number of cases of typhoid and typho-malarial fevers treated during
the Exhibition  period of 1876 was about double that treated during
the corresponding period of 1875.
   Still more convincing evidence in favor of this view is to be found
in an examination of the relation borne by the  number of deaths from
typhoid fever to the number of visitors to the Exhibition grounds. (See
Chart No. 4.)   It will be seen by the course of the solid blue line, in-
dicating the mortality from typhoid  fever, that there was no marked
increase beyond the ordinary mortality from this affection from May 1
to the last week of July, during which time the number of visitors in
attendance at the Exhibition was  low, as is shown by following the
dotted  black line  which indicates the weekly attendance. (See also
tabulated statement at foot  of page.)
   During this time, also, the number of strangers arriving  in the city
was especially small, the attendance at the Exhibition being chiefly of
Table showing Week ending ratio of		Mortality from Typhoid Fever in Philadelphia	Admission of Visitors to the Exhibition.	Attendance at the Centennial Hospital.
mortality May	13	7	235.251^	14
from typhoid "	20	10	"5,236	'9
fever to „ admissions and attendance J e	27 . 3	12 10	155,724 204,704^	5i 62
at Hospital. "	10	10	233,406	69
■1	17 •	12	216,536	117
a	24	12	232,535	•59
J«iy	1	10	210,108	204
"	8 .	9	315.853	301
"	15 •	10	'74,792^	301
"	22	13	166,744	252
"	29 .	18	185,464^	259
August	5 •	22	196,277	205
n	12	23	210,075 •	282
"	19 .	26	241,078	276
"	26	3i	347,082	334
September	2	29	321,997	348
"	9	24	446,032	347
"	16	12	495,694	359
"	23 •	3i	624,372	359
"	30 .	15	758,l6o	349
October	7 •	29	551,669	398
f<	14	21	584,011	3°7
"	21	10	700,600	322
a	28 .	13	641,021	336
November	4	15	628,348	322
"	10	16	596,102	211
 
REPORT OF THE DIRECTOR-GENERAL.
669
the residents of Philadelphia.  The large number of visitors attracted to Bureau of
                                                                   Medical
                                                                   Service.
the city by the ceremonies of the 4th of July, remained for so brief a
time that they exerted no influence upon the mortality from this cause.
After the week ending July 29, a steady rise in the weekly attendance
occurred, which continued to  progressively increase, with occasional
fluctuations due to  special causes, until  the close of the Exhibition. Ratio 0f
With this there was noticed a rise in the weekly mortality from typhoid mortality
                                                                   from typhoid
fever, which continued until the weeks ending August 26  and Sep- feVerand
tember 2, when, with a  weekly attendance of 347,082 and 321,997 admissions-
respectively, the mortality from typhoid fever was 31 and 29.  After
the latter date, although there  is a still further marked increase in the
weekly attendance at the grounds, the deaths from fever never exceeded
the figures above given; but,  on the contrary, after  October 10 there
was a  very marked  reduction  in  the weekly mortality from  this
cause.  The marked effect  of the intense heat upon  the  mortality
from  diarrhceal affections, not only in Philadelphia but elsewhere, has
already been shown (see pages 21, 22); and it is interesting to observe
that no similar effect was produced  upon the mortality from febrile
diseases.
   The  amount of  typhoid  fever  in  neighboring cities  during the No excess oi
Exhibition period was not more than usual  during the  correspond- [yphoidfcveT
ing months of other years, and this fact is  interesting when we bear in other cities'
in mind the statements  which were widely circulated at the time,
that very numerous cases of typhoid fever  occurred among persons
who  had  returned  home from their visit to the Exhibition.   It  is
difficult to conceive how this could have been so to any extent with-
out influencing perceptibly  the mortality from the  febrile  affections
during  that period.  It may therefore be stated, in conclusion,  that Conclusions as
                                                                   to prevalence
during the six months of  1876, from  May 10 to  November 10, there of typhoid
occurred  in Philadelphia an unusual number of deaths from typhoid fever
fever; that this excess over the usual mortality amounted to about
200 deaths; that the occurrence of this unusual mortality from typhoid
fever  was not due to the existence  of any special cause of that disease
in connection with  the Exhibition, or to the prevalence  in an unusual
degree throughout the city at  large of its ordinary causes; but that it '
was due to the  enormous influx of unacclimated visitors, who were
rendered additionally liable to the action of morbid influences of every
kind by their  mode of life while in this city.
   Having  thus spoken of the statistics of typhoid fever during 1876, Definition of
both in  this city and elsewhere, a few words only upon its character ^ho'lakriai
are called for in this report.   It  will have been observed that the fever-
terms typhoid and typho-malarial fever have been used.   The first of 
670
INTERNATIONAL  EXHIBITION, 1876.
Bureau of
Medical
Service.

Definition of
terms.
Characters of
typhoid fever
of 1876.
Ratio of
mortality.
these is employed, as is well known, to designate a specific febrile affec-
tion, characterized by a peculiar form of ulceration of the intestines,
and caused, so  far as is yet  known, by the emanations from decom-
posing animal  matter, and especially by those from  the evacuations
of patients having this same  disease.   The term typho-malarial fever
has been introduced of late years to designate a disease in which it is
believed the specific poison of typhoid fever exists, complicated with
malarial poison.  Medical opinion is  still somewhat  divided with re-
gard to the latter affection, although it is generally acknowledged that
such a disease,  due to the combined  action of the two poisons, does
actually exist.   It  seems probable,  however,  that the  term typho-
malarial fever has often been  used inaccurately, so as  to include cases
of irregular typhoid fever, and  probably  also  cases  of simple  intes-
tinal catarrh with marked typhoid prostration and  irregular febrile
action.
  We believe that the typhoid fever which occurred during 1876 was
not much  modified, at least here and in neighboring  localities, by
the admixture  of a  malarial element.   This  opinion is  based not
only on the characters  of the  disease as it  came under our notice,
but also  on the small  amount of malarial  fever of  any form which
occurred here during that season.  It  is true that, in a considerable
number of instances, the cases were termed typho-malarial fever  in the
returns to  the Board of Health, but we are convinced that the large
majority of such cases were either uncomplicated typhoid  fever of ir-
regular or abortive type, or else catarrhal diarrhoea with marked typhoid
prostration of system.  Indeed, we have more than once expressed our
belief that a considerable proportion of the deaths recorded as from
typhoid fever were in reality due to this latter condition.  The typhoid
fever itself was very irregular.   In many  cases it ran a much shorter
course than in the usual typical  form, not exceeding 15 to 18 days.
Another marked peculiarity was  the frequent occurrence  of hemor-
rhage from the bowels, which took place in a larger  proportion of
cases than  usual.
  It is, of  course, difficult to estimate  the ratio of mortality of  a dis-
ease occurring under such  circumstances, but from  the data in our
possession it may be  stated as about 18 per cent.  As an  illustration
of the extent to which typhoid fever is influenced both in its degree
of prevalence as well as in its mortality by epidemic  causes, which it
is difficult to appreciate, it may be stated that in Paris (where the mor-
tality during the previ'ous three years was as follows: in 1873,  1007;
in 1874, 846;  in 1875,  1001) the number  of deaths from this disease
during the year 1876 amounted to 2073, and so severe was  the type 
REPORT OF THE DIRECTOR-GENERAL.
671
that the  rate of mortality rose as high as 35  per cent, of all  cases
treated.
  We have entered thus at length into the discussion of the typhoid
fever of 1876 on account of the large amount of public interest which
this disease attracted during the Exhibition period.   In summing up
our remarks upon the  sanitary condition of Philadelphia during this
interesting time, it will be  seen that the general results do not differ
materially from those  stated in our circular issued  in the latter part
of September.   (See Exhibit A, Circular No. 3.)
  At that time the data  in our possession did not enable us to dis-
tinguish  between  the  different  classes  of diseases  with  as  much
accuracy as we have done in the following table, which embraces the
entire Exhibition period:
Bureau of
Medical
Service.
Circular No 3,
issued in
September.
London.......
Philadelphia
Baltimore....
Chicago......
Boston........
Brooklyn ....
Paris...........
New York...
Berlin.........
3489
 900
 35o
 420
 342
 506
1851
1054
 980
Sd
hS
37,592
10,294
 4,020
 4,927
 4,i44
 6,453
23,735
'5,492
16,407
* S
2L54
22.77
22.97
23.46
24-33
25-49
25-63
29.40
33.86
r* n,
6905
2485
1524
2277
1422
2583
5884
Qo-
3 *

Z »■
<
 3-99
 5-5
 9-2
10.8
 8-3
•X W



o c
606
450
393
S3
C < H
,0 X
c-> «<
3149
1333
 652
 918
 772
1485
3527
<j ft,
1.80
2.96
3.72
437
4-5
5-86
6.69
Results
brought up
to close of
Exhibition.
   It will be seen from this that of the nine large cities from which we Favorable
 have been able to secure returns, Philadelphia was second to London pos^on oi
 alone in point of average  total  mortality.   It will also  be seen  that Philadelphia.
 while the  annual  death-rate from typhoid fever per 1000  living  in
 Philadelphia was higher than  in  any other of these cities excepting
 Paris, the annual death-rate per  iooo from all  zymotic diseases, which
 include diarrhceal affections, continued and eruptive fevers, etc., was
 relatively smaller  in  this city than in any other save London.   This
 result is chiefly due to the  relatively small  mortality from diarrhceal
 affections, which gave an annual death-rate per iooo of only 2.96,  as
 contrasted with 6.69 in New York, or 5.86 in  Brooklyn.
   If we  have  been correct in our conclusions previously stated  (see
pages 14, 25), it may therefore be confidently asserted that  Phila-

  * By zymotic diseases are  to be understood all diarrhoeal affections; eruptive fevers, sucn
as smallpox, measles, scarlatina, etc.; typhoid and malarial  fevers; diphtheria, etc. 
672            INTERNATIONAL EXHIBITION. 1876.
Bureauof    delphia  has again vindicated her claim to be regarded  as  the most
Sem'ct      healthy  city in the world, with a population of over 500,000, with the
          single exception of London.
            Some of the causes of this  are stated in the circulars alluded to (see
          Exhibit  A), and  it is owing to the nature of these causes that the un-
          precedented risks of a sanitary nature connected with so vast an influx
          of strangers to the city were  met with  such signal success.

Acknowiedg-    It is proper to state that in the establishment of the Hospital a full
          supply of medicines was presented, with great liberality, by the follow-
          ing  well-known  firms: Messrs. Powers & Weightman, Rosengarten
          & Sons, Hance,  Brothers, & White, and  Bullock & Crenshaw, all  of
          Philadelphia. 
BUREAU  OF  MEDICAL  SERVICE-EXHIBIT A.
OFFICIAL  CIRCULARS.
UNITED  STATES  CENTENNIAL  COMMISSION.
INTERNATIONAL EXHIBITION, 1876,

            PHILADELPHIA.
Bureau of
Medical
Service.
BUREAU OF MEDICAL SERVICE.
CIRCULAR NO. I.
  Owing to the very large number of persons  who contemplate  a visit to Philadelphia Circular No
during the coming summer, it seem'; important that the utmost publicity should be given
to all facts bearing on the sanitary condition of the city.
  The following statistics, which have been obtained from the most authentic sources ac-
cessible, represent the mortality in some  of the chief cities of the world during the past
four or five years:
	Number of Years.	Average Population.	Average Total Mortality.	Average Death-Rate per iooo.
	5 S 4 5 4 5	648,560 994.458 950,000 3,284,488 1,851,792 744,831	20,424 29,601 28,420 76,74' 42,724 i6,573	31.42 29.93 29.91 23-33 23.06 22.27
				
Berlin....................				
				
				
				
				
  While thus showing an average rate of mortality more favorable than that found in any
other city containing over 500,000 inhabitants, Philadelphia has recently (1874) attained
a degree of healthfulness almost unparalleled, viz.: with a population at that time of 775,000,
the number  of deaths was  but 14,966, giving a death-rate  of only 19.3 per thousand.
These very favorable results are largely clue to the abundant and cheap water supply, and
to the opportunities given, even to the poorest citizen, for the enjoyment of  pure country
air in the great Fairmount  Park, which  contains 2991 acres.  The extent to which this
is valued  by  the citizens may be inferred from the fact that during the year 1875 the Park
was visited by over eleven million persons.
  The  most  powerful influence of all, however, is  the absence of that  overcrowding of
the population, which is the most fruitful source of  sickness  and  death  in many quarters
of  nearly all other large cities.  This will be  more clearly comprehended when  it is
remembered  that the 817,488 inhabitants of Philadelphia are spread over an area of 129^
square miles, which are traversed by more than one thousand  miles of streets and roads;
and that the city contains, in addition to other kinds of buildings, I43>000 dwelling-houses
occupied  by  families, —a number exceeding by over 40,000 that of  any other  city in
America.
  The climate of Philadelphia is also, on the whole, a favorable one, although  presenting
many of the peculiarities common to inland localities.  The mean  annual temperature of
the  last ten  years is 53.730 Fahrenheit; the  average annual  rain-fall is about forty-five
inches.
                                       43                              673 
674
INTERNATIONAL  EXHIBITION, 187b.
Bureau of
Medical
Service.
Circular No.
  The following table exhibits the mean temperature of each month for the past ten years,
showing that the  range is far  less extreme than is found in many other less favorably-
situated localities :
 MEAN TEMl'ERATURE
January  .
February .
March
April
May
June
Circular No. 2.
^FAHRENHEIT)  OF EACH MONTH  DUR
       .  32.720 F
       •  33-12  "
39.16
53-36
63-24
73-54
July
August
September
October   .
November
December
THE PAST TEN YEARS.
           -   78-74° F.
           •   75-92 '•
           .   67.72 "
           -   56-°3 -
           •   43-34 ll
           .   33.92 "
<
  It is thus seen that only during the  months of June, July, and August does the mean
temperature rise to a high  point.  During this period  there are very rarely any prevailing
epidemic diseases; and the chief mortality occurs  among children, especially among the
poorer classes.
  The health of Philadelphia at present is unusually good.  Timely efforts have been made
to secure an abundant water supply to meet the great increase in the demand which  musi
be expected this summer, as compared with previous years.  Constant watchfulness will
be exercised by the authorities  to  maintain cleanliness, and to avoid  or remove every
possible cause of disease.
  Within the Exhibition grounds a rigid sanitary inspection will be maintained, under the
control of the Bureau of  Medical Service;  and thus a guarantee will  be afforded that  no
cause of infection or disease will be allowed to  occur through neglect of this important
duty.
  The object of this circular has been to  call attention to the unusual sanitary advantages
of Philadelphia, and to the preparations which have been made to insure the highest pos-
sible  degree of healthfulness  during the  approaching Exhibition  season. It is  proposed
to issue at certain intervals other circulars, announcing in an official  and  accurate manner
the  sanitary condition of the city, so that entire security may be felt by all who  desire to
visit the Centennial International Exhibition.
                                   WILLIAM  PEPPER,  M.D., Medical Director.
  15th April, 1876.

                                  CIRCULAR NO. 2.
                  [POSTER USED IN THE  ISUILDINGS AND GROUNDS.]
                    THE BUREAU OF MEDICAL SERVICE
has been organized for the purpose of rendering immediate gratuitous aid in all cases of
sudden illness or injury occurring to visitors and others within the Exhibition grounds.
  The Medical Director has secured  the  services of a staff of six well-known  and able
physicians, who will be on duty from 9 a.m. to 6 p.m., at the  Hospital building, -which is
centrally situated in Landsdowne Ravine, in the rear of the Judges' Hall, and is comfort-
ably and suitably arranged for temporary  relief and comfort of all in need.
    In connection with the Hospital service, stretchers are placed at many points, by which
such cases  may be immediately carried to the Hospital, and an ambulance by which, when
necessary, they can be removed to their residences.  Any person needing medical aid may
apply to the Guard, who are instructed to assist them to the Hospital without  delay.        m
    The Hospital may be recognized by its flags, one being the United States flag, having  ■
the words Centennial Medical  Department printed across the centre; the other,  a white  '
flag,  with  a large red Geneva  cross in  the centre.  The  officers  will  be recognized by
the badge, a white shield, with red Geneva cross,  above which is  a blue enameled bar
surmounted by the American eagle.
   May 10,1876.                       WILLIAM  PEPPER, M.D.,  Medical Director. 
REPORT  OF  THE DIRECTOR-GENERAL.            675
                                  CIRCULAR NO. 3.                                   Bureau of
                      BUREAU OF  MEDICAL SERVICE.                        Medical
                                                                                     Service.
   In a former circular issued  from this Department, the exceptionally favorable position  circular No.
which is occupied by Philadelphia, in comparison with the other great cities of the world
[i.e., cities  containing over 500,000 inhabitants), in regard to its sanitary advantages and
average rate of mortality, was shown by carefully-prepared statistics.   In anticipation of
the unusually large number of visitors who would undoubtedly be present in the city during
the continuance of the International Exhibition, great efforts were made by the municipal
authorities, as well as by those in charge of the Exhibition grounds, to obviate every cause
of disease.   The details of these  arrangements will be published in the official reports of
the various departments, which will appear after the close of the Exhibition.
   It is owing to their thoroughness that, despite the very severe and prolonged heat of
June and July, and the vast number of unacclimated strangers constantly present in Phila-
delphia since the 10th of May, the general health of the city has been remarkably favor-
able.   With the  exception of the four weeks ending July 22, the range of temperature for
the past five months has been  about the average.  Thus, for the entire  period of twenty
weeks since May 10, the mean daily temperature has been 71.30° Fah., while the average for
the same months during the past ten years has been 71.82° Fah.   The mean temperature of
the four weeks referred to (ending July 22), on the other hand, was 80°, 83°, 83°, and 8i°
respectively, giving an average for the month of 81.75° against 75.50 Fah., the mean temper-
ature of the corresponding period of the previous year.
  The following table, showing the relative mortality of  Philadelphia and some of the
larger American and European cities, has been prepared with strict care from the official
records.  The periods selected for comparison correspond as closely  as  possible.  It will
be seen, on careful examination, that the past season has not been an unfavorable one :
			B O J	* w		5 s «	« S	« S
	Z	k	6) - < * 2 H	u 2	w 8		sg	sg
	0	"w	Mortality from Typ» nd DlARRHi NS.		ID	»t*Q	M *•	B *•
	<				r- < < r3 H < X ^ 2 0	< * 5 </i	«S ■	5g
CITIES.	» A. 0 PL, Q	H>-| ^ Z O ,		32 < s (- > 0			Pi w 8 • ;5 <n X> < u G	Dig S58
	h <	\\	< 0 w K in .. r.	PS a u. 0	0 ..	JPOJ	O|0 -3h	J Q <
	S P w	5 »	Averai Week Fever Apfec	< ii in 2 a a	< *	g 8 1 e z 2 >" x <	< O	
	3,254,260	26 weeks, including the quarters ending June 19	105.5	291	1467.4	1.66	4.62	23.40
								
		and Sept. 26, 1875.						
Philadelphia-	900,000	20 weeks, from week ending May 13 to week ending Sept. 23, 1876. 18 weeks, from weekending	83.8	112	406.5	4.84	6.47	23.48
	420,000		52	80	196	6.44	9-9	24.27
		May 13 lo week ending Sept. 9, 1876. 18 weeks, from week ending May 13 to week ending Sept. 9, 1876. 19 weeks, from week end-						
	342,000		367	57-4	161	5-56	8.73	24.48
								
	360,000		48.9	58.1	172.36	6.91	8-37	24.80
		ing May 13 to week ending						
		Sept. 16, 1S76.						
	1,851,792	26 weeks, including the quarters ending June 25	64		896	1.76		25l6
								
		and Sept. 24, 1875.						
	506,223	20 weeks, from week ending May 13 to week ending Sept. 23, 1876.	75-7	"5	262	7-74	11.81	26.91
New York.....	1,064,236	19 weeks, from week ending May 13 to week ending	^74-9	262	629.7	8.52	12-79	30.73
								
		Sept. 16, 1876.						
	950,000	26 weeks, including the quarters ending June 30	201		626	10.92		34-32
								
		and Sept. 30, 1873.						
 
676
INTERNATIONAL  EXHIBITION, 1876.
liure.iuof         It will be further observed that, as in the table published in the former circular, Phila-
Medical      delphia occupies an  exceptionally favorable position.   With the exception of London,
Service.      whose rate of mortality is nearly identical, Philadelphia presents a considerably lower rate
            than any other of the great cities, while in comparison with its nearest neighbors, New York
            and Brooklyn, its superiority is both striking and suggestive.
                In calculating the rate of mortality in Philadelphia during  the past twenty weeks, the
            population has been estimated  at 900,000.   Those who have carefully studied the  move-
            ment of its  population think, however, that in consequence of  the large influx of visitors,
            this estimate is  below rather than above the mean daily population.   It must further be
            borne  in mind that, while a  considerable portion of its more favored classes were as usual
            absent from Philadelphia during the summer months, the lower classes, among whom the
            mortality is  always greater at this season of the year, were largely reinforced.   If in addi-
            tion to this it is considered that a comparatively large amount of sickness might have been
            expected among the vast throngs of unacclimated visitors reaching the city after  long and
            hurried journeys, and exposed to excitement  and excessive fatigue, the full significance of
            the remarkable  table above given will, it is hoped, be appreciated by  all.   As one of the
            most important factors in the maintenance of public health is the purity of the water supply,
            it is with great satisfaction that we learn from the official report furnished by Dr. Charles
            M. Cresson, the distinguished analytical chemist, that the purity of the water supplied from
            the Schuylkill River to  the Exhibition grounds and the neighborhood is fully up  to the
            standard of the past four years.
                As the summer months, during which time alone any fears could be entertained for the
            development of widespread disease, have passed with such   gratifying results,  it  is not
            premature to express the feeling of thankfulness and congratulation that during this im-
            portant year Philadelphia has been  favored with the same  exceptionally low rate of mor-
            tality she has so long enjoyed.
                                                WILLIAM  PEPPER, M.D., Medical Director.
              September 26, 1876. 
  Ilkistnvting the Jfit
upon the Eochiliiiori
   wvfitsidefik upon thalknilrition favunds, thNiuriherofCases of Sickness, the Number of Cases ofManJuxfyajid/ttw Numberof"Cases ofJIelriMyeackWeek among Residents
5 wilkthe WeeklyMortality fivmall Ca^sesutu\eCl^\ofFhiIa^^                  Obsmattonsfoi the same Period/fimti^       U.S. Signal Office
January 7877.
    DC
-• Weekly Mortality fhmiya^Giuses in-Philadelphia.
____. WkktyMtmber of Personsresiding i^Jon the Exhibition (rrounds.
—-• Weekly Cases of Sickness amojig fiesidektsupon the J&kibUwh Grvunds.
——* Vfeekty Cases o/'Miarrhaea. among\Seside^dsuponthe£a^vihiiiort(h^iirids.
 ---* Weekly Cases otWebilifycmwngResiderttsicport theEochibit in Grounds.
   fUekfyaverage Maxununv and Minimum Ihnpenitwre.
1                                           II
^2fean,fVeektyIfumidMy.-Boint of Saturation, ,{00.
— Mean. Weekly Thermometer.
THE GRAPHIC CO.N.Y
JHekly JfairvFaUiri uiekes.
-* Mean^^ffeeklyJieadingofSaronieter. 
flktstmting the WedlyMrnwionxtotlw Centennial InternationalPMdbition> tie Number of Patients treMMatthatfospitedofth&JlurmuofMedru/^ trvi^J^wnde^natS
treatedforEvnaurtion, artd Effects of Peat, tfoMmler of Patents treaM for Sm                                                       O'tyofPklnd^i'mi He Weekly Mortality from  Sim -
Stwkem Phzladdpkuzand[tfeteowkgiail'Observations forPiesamePerM, furmstwd by (fa. US. Signal, Office
Weekly Mortality fhwv all CaustemPlnladdphia.
Weeltfy Mortality thorn, Sunstroke in the CtiyofPhilarfe/pkUv.
THE GRAPHIC CO.NY
January 187F.
                                                                       ,.-----_.  Weititysldntissi/)n9totheCentmnialfnie
                                                                                Weekly average' Jfaxinuartajid^ MimmuJTL Temperatdre.
•-• WedfoTotalofAtiauiaMvatMospitala^          Grounds.              v-------^Jfean WeeklyHumidity-Point of ScUt"*ttion, ftk
   WeeMy Total of Cases affected tyfflcatajid]^                               •—------• Mean Weekly Thermometer.
•yah
------Weekly Total Casesof'Sunstrokeamong Visitorstreatedsat the Hospital.
■m Mean Week^ Reading o/'Parameter. 
 lflusbtituiqtheWeejfdyAdmi&                                                                           each  week atdmHospitdofthePurednofMediiydSe
PieirrhoemI Affections each Week, wiihthe WcJdyMortality hum all Causes in tficCityofBtilctdetphm<,- the WeeklyMortality from  BiMrhe^PeseeisesuiPhihM         Meteorological Observations for
the same. Period furnished, by the U.S. Signal Office.                                      j
																																											
| Chart IH				May					Jwne>				JiHy								August				September								October				November						
				13th.		20th,.	27th.		Jnl.	10th.	mk.	24ih.	1st.	8ttv.	15th.		2ZruL		ZOOt,	5itiv		12th.	19th,.	26th.	2nd-.	9th.	10th,		23rd,		30th.		7th.	14th	2Ut.	2Sth.	4th	10th.					
									■ •	■	t	-_■-	■	-					I	1			h—■-	|	■	|							1		■	■	m			J)eqreesFahrenheit o.oo ^\			
r-----									1	I		JU	|						1				1	■	rt	1					-		T			1	~*I			17 rs lot '	.23 -	'	
				-						1	I		J										I			1	---									—■—	—X				.50 -		
r \																																					j				.76 -		
- seo																																					■ j			9S°	1.O0 -		
— 8-40		a"			_..																					---				-	._									93°	1.BS-		
— 8ZO		S-																									___										I				1.60 -	~&3-------	
— 800		Q)																																			i				1.76 -	—?£-----......—	
— 780		^																					---	:—:nz		---											i;			87°	2.00 -	—^-------	
N. — 760		*B																																			!j			8S°	2.26 -	"^------	
— 84O.O0O	— 740	§L																	---			---				---											),				2.50-	>«	
— 82O.000	— 720	*$£													. —\		^s~-			/\					—		—														2.76 -	f-	1:.. __,
— SOO.OOO	■ r? -7°°					■——														i\																	|			79°	3.00 -		
— 780.000	?5 — 880	&																																			J				3.26 -	~x~ - -	
— 760.000	V* - 660																\ J.														•						I			75°	6.60-	-gr - —\	
— 740.000	\ ~ 64°	s												-h—	---		\ \			\ ' /		\									t ' •										3.76 -		
— 780.O0O	s. -e**__.	<§F									/ ' \								\ !/ /												V i						j				4.00 -	. .	
■ - 700.000	^ — BOO	"P																	. .		/										,' ^\'				/ •		. y				4.26 -		
— 880.000	lift — S80	%				/ \					1								_i					\						/					//\;						\ 4.60 -		
- 680.0OB	^ — seo	■&		/		\				1									/					\						i					it	\				8S° ( 4.78-			
- 040.000	& ~54°			s						/		\	J						L_ 1					\						t			( V.		'•	•■»».	I				6.00 -J		
- eto.ooo	§" - sso	s								/									, /					\_^					/ \														
- 600.000	SJ- — soo	ic								k /									^ /										/				1	\ ~7			.....).-	**•		39°			
- 680.000	_|,„ =_««_	■ fcs								v /									V														»	Vv							— 80.ZSin.\		
- seo.ooo	S3 -•««	F								\/																			'				t ^#										
- 540.000	°J — ^^<j																			—-^																							
— at o.ooo	^T — 420	f f																		V '																				61 "			<h
- SOO.OOO	^ - *00	s																									i										V	.		49°			-r—
- 480.000 > £ - 880		&																									/										■	\			- 29.76 „		.__§,-------
— 480.000	*2 —360	«£																								/	-♦--										I	\		46°			<a ""
- 440.000 — 420.000	S _ .f*0	—ft-										/	---											r-~'	^vT	•8HC					-^									■*3°			Lj ■ —
	. kt —320											---		P-T-										/		SW-^					\				r"**""	r^*-							rr i
— 400.000	^ — 300														-*								/			'							w^"1	k^**>»^			\ i			39 °			-i---
- 880.000	^1 — 2*0		£—										7							1		/•—	/														\!				— 29.26 „		
— S60.000	Jj" ~ 2SO	§															K		""•«.	/					*												' t						a»
—34O.000	Sj — 840	«										/							\		/			»«	/															33'			i
— 820 000	^ —220	&											"?...... 4- -----	* > - - t*-^ —fC^\—, 1 v					\	w'				j	^x«													\					
— 30O.000	§■ - 000	h							'						,» \					V				i														-\--					
— 280.000	S - 180	^										/			*',\								/		-•••,									---						Saturation, 700 - x*.?s „			
— 280.OOO	^ — /SO	—&—										s			'i								>			s -*'J	' ">		*»♦.											J			
- 240.O0O	fc*1' _ 1*°	---Os---								L»-ft^-	/	"••*"».					*\.						\J"'			*			"•♦.							/W.__	mim						
— MO. 0 oo	S* - 120	—V-							S	s ^i	ytr"		"^»		\		*^*r														**.				s	'	\			J			
— ZOO.000	*«. — too -^-----	►,'							*	,'		,			\				%»x	,	S									___							Z3"						
' — 180.000	& ~"	^					*			/		'•'/			'• ^.							m_											rw"1				izK					"--------•	
— 160.000	S- -60.	&							+-—-J			.•V																										*»		■		—.....-......—	
-*- 140.0 00	5s °~40	to ^—$£—				,» 5-					. -*' >																																
— ito.ooo	— to ----r^-oj	S		e-"..5		—^>°°°°9	■ < >j		^>»»»		=T8---								-----,																								
Total Weekly Rain Fall.				1.7Sin		36 in.	I97in		.33in.	.52av	.55in.	.48 in,	.63irv	.03 in.	I.SSin,		1.16in,		.ZSirv	Z.kzin		.00 in,	:07in	.ZZirv	.37in.	,59in,	1.31in		4J>0m		1.60av		.SOin	.OOin	.75m	.0)'in.	.ZZii,	7.49in					
Number of clear days.				1		3	4		3	6	1	5	5	4	2		3		Z	f		Z	Z	Z	1	Z	.1		0		Z		5	4	4	1	s\	&					
Number of cloudy days.				6		4	3		4	Z	6	Z	Z ,	3	5		4		5	)•		5	3	5	6	5	e		7		6		I	3	3	6	z \	3					
Number of days with East wind.				1		3	1		I	1	Z,	0	0	1	3		4		1	6		4	3	3	0	3	5		5		Z		1	1	3	4	3	4					
Number of days with.West wind.				6		4	6		5	6	3	7	7	6	4		3		6	!		3	Z	4	7	4	2		Z		6		6	6	4	3	4	2 46°					
| Mean Thermometer Weekly.				62°		54°	64°		67°	71"	Tl°	7Z'	8t°	33"	33"		SO'		71°	to*		78"	76°	74°	73°	67°	63°		04°		38°		34'	50°	48°	SO"	53°						
Mean Barometer Weekly.				29.93		30.20	30.04		29.97	30.04	50.14	29.04	Z9.90	29.94	29.00		3Q 03		30.0 f	36.08		30.14	Z9.96	30,04	Z3L96	30,OZ	30.07		29.77		X9.93		Z0.91	30.08	30.04	29.96	30. Oi -4-	30.07					» .
7HEGRAPH1C CO.N.Y
January 1877.
    DC
Weekly Mortality from, all Causes in, Philadelphia,.

Weekly Mortality fhm, tliarrhaeat Diseases in, Philadelphia^.

Weekly Admissions to the Centenniat' fnternational Exhibitions.

Weekly total Attendance at Hospital in Exhibition Grounds.
..  WeeUyAttendanceat Hospital troni Hiarrhacal AtTectioris.

-e^tfean Weekly tfumidUy- Point of Saturation ttltl.

—• Mean Weekly Thermometer.

-k Mean Weekly treading ofMarometer.
Weekly tfainFallin inches. 
  lllmtmtt^ tlicWeekfy Populalw                                     the We^h^Sidmss/hnioPlmtseSj IfaWMyfasesofaMMr^
 (hses ofTypfwidFever (including Jyykho-Malar^FeytT) among mlh'iclentsiipontnel^d^n tsrvundr, with the JfccfyyMrtalityfrom ftphnidFeverinthe City of Philadelphia mid Metw:
olotfiad Dbsermiiens for tfe sam period htrrtished by the U. $. Signal Office
January 1877.
._._. WeefctyMmierofPersom residing upa i theIbchibitwn Grounds.
____• Weetsfy' Gises of Sickness ajwny l&su^^                                  J^m
 .----fflekly Ibtat ot^tksesofatl' Febrikdisease, * among, t^esutent^npm,£xh ^Grounds.
 ........ffleeldy Cases oftmtymitterdFetvrwnong Residents upon the Inhibition Grounds.
      Weekly Casesof'TyphoidFeveriwdudiry■{ phaMaleriatJam^dieIes!fupon£xh?6r^ ^
    , Mekl}> Mortality firm, all GmsesinFhifj^dphia,.
_^ Weekly Mortality front Typ* wid Fever in tlie CdyofFhiladepMi.
~m Weekly Admissions to the Gmtt <tniat/ntern/nion^lFxtTibitlon.
 I Weekly Fain Fall in. i/irlies.
-^Meanl^eld^ffunddi^-Poin^ofSatuTatiorL 100.
_ Mean Weekly Thermometer.
__«Mean JfakfcJReadirig ofBat vmeter.
TheGcaphicCo.N.Y