JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
MARCH, 1949 VOL. 41 No. 2
ORIGINAL
COMMUNICATIONS
Practical Correlative Anatomy of the Bronchial Tree and Lungs*
JOHN FRANKLIN HUBER, A.B., M.A., M.D., Ph.D.
Professor and Head of the Department of Anatomy
Temple University School of Medicine
U NTIL relatively recently, clinical need for
detailed knowledge of the structure of the
bronchial tree and lungs has been well ahead of the
knowledge which the anatomist has made avail-
able. A glance at any of the standard textbooks of
anatomyt would be sufficient to prove this point,
as the statements concerning details of bronchial
branching and its relation to the lungs are unsatis-
factory and meager. This lack of readily available
information was brought home to me quite em-
phatically several years ago by the fact that Dr.
Chevalier L. Jackson began asking me some ques-
tions concerning bronchial branching and distribu-
tion which I was unable to answer. As the result
of these questions, I began, in cooperation with
Doctor Jackson, an extensive study of the bronchial
tree and its relation to the lungs. Some of the
results of these studies will be reported to you
today.
FUNDAMENTAL CONCEPT
In thinking about the lung during the course
of the dissection and study of many specimens, a
concept of the structure of the lung became appar-
ent to me which seems to be fundamental to the
understanding of the problems which face the
clinician. Very simply stated, this concept is that
the lung, in its ultimate analysis, is the complete
or total branching of the bronchus leading to the
lung. Of course, in addition to the total branch-
ing of the bronchus there are the blood vessels,
nerves, lymphatics, and connective tissue, but bas-
ically the lung is just the total branching of the
*The sixth annual Austih M. Curtis Memorial Lecture
given at Howard University School of Medicine on
May 27, 1946.
t Since this lecture was presented recent editions of
Gray's Anatomy and Grant's Method of Anatomy
have come out which include details on this subject.
bronchus going to it. If one carries this thought
just a little farther, it becomes obvious that as the
main bronchus gives off a branch which goes to
what has been classically called a lobe, one can
think of that lobe as the total branching of the
bronchus going to the lobe. Carrying this thought
still farther, c4ch branch of the bronchus entering
the lobe of the lung would divide to form a defin-
ite portion of the lobe. For example, there are
three branches of the right upper lobe bronchus,
and the ultimate or total branching of each of
these three branches forms a definite portion of
the right upper lobe, so that one can think of the
right upper lobe as being divided into three parts
on the basis of the bronchial distribution. This
concept is simple and, though it is not new (Mack-
lin and Macklin' emphasized that "the lung is
the bronchial tree"), apparently many individuals
do not make use of it, consciously at least, in their
thinking about the lung. It seems to me that it
might well be the basis for the beginning of
thought concerning the structure of the lung. In
Figure 1 there is an attempt to put this concept
into diagrammatic representation.
BRONCHOPULMONARY SEGMENTS
AS DEFINITE ENTITIES
I am sure that many of you are wondering if
the subdivisions of the lobes which are made by
following this concept are purely theoretical. They
definitely are not. The lobes, of course, have been
recognized as entities for a long time, since in most
instances they are separated from each other to
some degree by indentations of pleura which we
speak of as fissures. However, as one looks at the
surface of the lung, in the majority of cases it is
not possible to see the subdivisions of the lobes.
Actually, however, these subdivisions are just as
50 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION MARCH, 1949

Figure 1. Diagrammatic representation of the concept that the lung is basically the total branching of the bronchus
which leads to it and that the total branching of each bronchial branch forms a definite subdivision of the lung.
An anteromedial view of the right lung is shown with some of the lung cut away. At "A" is the fissure be-
tween upper and middle lobes. At "B" is the intersegmental plane between the anterior and apical segments and
at "C" the plane between the apical and posterior segments. No attempt has been made to show planes between
subdivisions of the segments which would be similar to those between segments.

definite entities as the lobes are. There are several
ways in which one can quite readily prove this
to be true. For example, one can demonstrate these
subdivisions of the lobes by tying a cannula into the
bronchial branch which is going to one subdivision
and injecting colored gelatin into that bronchus
with the result that the subdivision of the lung is
filled with the colored gelatin. Then by tying can-
nulae into the bronchi of adjacent subdivisions and
putting in different colors, one can see quite satis-
factorily the delimitation of these subdivisions and
see that they are definite entities. It is also fre-
quently possible to demonstrate the subdivisions
by mere injection of air into one subdivision at a
time by inserting the cannula into one bronchus
at a time (Figure 2). In many instances one can
dissect along the thin planes of connective tissue
which separate one subdivision from the next, and
in that fashion delimit the subdivisions (Figure
3). Further evidence of the fact that the subdivi-
sions of the lobes, which are formed by the total
branching of the branches of the lobar bronchi,
should be considered as significant entities comes
from the fact that the majority of extra fissures
VOL. 41, No. 2 Practical Correlative Anatomy of the Bronchial Tree and Lungs 51

Figure 3. Photograph of the medial aspect of a left

lung in which the lower (fingular) division of the
upper lobe has been almost completely separated from
the upper division by careful dissection. The lower
division was inflated at the time the picture was taken.

Figure 2. Photograph of the medial aspect of a left

lung in which the superior segment of the lower
(lingular) division is inflated.

which one sees in the lung are placed at the planes

of separation between these subdivisions (Figures
4, 5, and 6). To give some indication of the inci-
dence of these extra fissures, one might mention
the fact that the two major portions of the left
upper lobe show some indication of separation
on surface examination in about 50 percent of left
lungs (Figure 4). The next most common extra
fissure is between the medial portion of the base
of the right lung and the rest of the basal portion
which is present to some extent in approximately
15 percent with reasonably good separation in
about 6 percent (Figure 5). There is some indica-
tion of an extra fissure between the superior part
of the right lower lobe and the basal portion of
the lobe in about 6 percent with good separation
in about 4 percent (Figure 6).
The name bronchopulmonary segment is becom-
ing fairly commonly used as a name for the portion
of lung substance which is the total branching of
a bronchus and, in general, it is being limited to
the subdivisions of lobes which are formed by the
direct branches of the lobar bronchi (direct
branches of "division bronchi" in the left upper Figure 4. Photograph of the medial aspect of a left
lobe). lung having an extra fissure between the upper division
and the lower (lingular) division of the upper lobe.
52 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Figure 5. Photograph of the basal aspect
of a right lung having an extra fissure be-
tween the medial basal segment and the
other basal segments of the lower lobe.
THE BRONCHI AND RELATED SUBDIVISIONS
OF THE LUNG
In examining a specimen, such as the one shown
in Figure 7, one readily sees the trachea dividing
into right and left main bronchi. In following
down the right main bronchus, one comes to the
branch for the upper lobe, next the branch for
the middle lobe, and then the continuity into the
lower lobe, which can be thought of as the branch
to the lower lobe. Following down the left side,
one comes to the branch of the upper lobe, and
branch for the lower lobe.
As one examines the right upper lobe bronchus,
he finds that it ordinarily divides into three
branches. These three branches distribute to the
portions or subdivisions of the lobe as shown dia-
grammatically in Figure 8. The bronchus to the
right middle lobe is seen to divide into two
branches which distribute to the subdivisions or
portions of this lobe shown in Figure 8. The
bronchus which enters the right lower lobe first
gives off a branch which goes to the upper part
of the lower lobe and then gives off four branches
which go to respective portions of the basal part
of the lower lobe (Figure 8).
In looking at the bronchus to the left upper
lobe, one sees that it divides into two branches-
one of which goes to the portion of the left upper
lobe which corresponds to the right upper lobe,
the other goes to the portion of the left upper
MARCH, 1949
Figure 6. Photograph of the postero-lateral aspect of
the lung in Figure 5 showing an extra fissure between
the superior segment and the basal segments of the
lower lobe.
lobe which corresponds to the right middle lobe.
Each of these two branches in turn divides into
two branches which distribute to or branch out
to form the portions of left upper lobe as shown
diagrammatically in Figure 8. In looking at the
bronchus going to the left lower lobe, one sees
that its branching is quite similar to that of the
right side. The chief difference is that two of the
branches which form portions of the base of the
left lower lobe are coming from a common stem,
so that one perhaps should think of three broncho-
pulmonary segments making up the basal portion
of the left lower lobe in contrast to the four bron-
chopulmonary segments which one finds in the
basal portion of the right lower lobe. The bron-
chial branching and its distribution is shown in
diagram in Figure 8.
NOMENCLATURE
So far in the discussion I have described the
structure without giving names to the things which
have been described as it seems to me that the first
thing which should be done is to come to some
agreement upon the structure before there is an
attempt to give names to the things which are
VOL. 41, No. 2 Practicall Correlative Anatomy of the Bi-onchial Tree and Lungs
.... .................... ...... . .....
..........
.....
.....
...
Figur
7. Phtgrp of a:spcie of th.adlpr fth rce n h
asfra tebachscmngdrclyfo*h "sg etl broch about 2/3natur..sz.
described. As Doctor Jackson and I discussed
the question of terminology during the progress
of our studies on the bronchial tree and lungs, we
felt that there was no satisfactory set of names
available, and that it would be worthwhile to
suggest a set of names which we hoped would be
acceptable to the anatomist and would also appeal
to the clinician. The nomenclature which Doctor
Jackson and 12 have suggested is based on several
principles which we think are important. It seems
to us that if there is a definite relationship between
the bronchial branching and the subdivision of the
lung, or, in other words, if we find it convenient
to subdivide the lung on the basis of bronchial
distribution, then there is no need for naming both
the bronchial branches and the subdivisions of the
lung. If one names either one or the other, the
name can be used to indicate both the subdivision
of the lung and the bronchus which is supplying
_ .......... ...... ... ..~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.
........-~_~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~. . . ..
.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~...
it or branching out to form it. It seems to us that
it is easier to name the subdivisions of the lung
than it is to name the bronchial branches. We there-
fore have attempted to find names for the parts
of the lung which would be readily understood and
which would consequently not have to be memo-
rized. In the classical nomenclature the lobes of
the lung are named by their position in the lung.
It is logical then to name the segments by their
position in the lobe and thus have a common basis
of naming running throughout the nomenclature.
We found that we could name the segments in
the right upper lobe apical, anterior and posterior
as one sees them by looking at the diagram of
lateral or medial view of the lung (Figure 8). The
two segments of the middle lobe have a medial
lateral relationship to each other and are named
accordingly the medial and lateral segments of the
middle lobe.
54 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION MARCH, 1949

r
0
r0
L-J r-
C 0

w0

Lcer-al View Loteral View

RIGHT LEFT

Medial and Basal Medial and Basal

View View

co

Figure 8. The tracheobronchial branching as far as the "segmental" bronchi correlated with the subdivision of the
lungs on the basis of bronchial distribution. The terminology used is that suggested by Jackson and Huber.2 Be-
cause of insufficient space the word "segment" was omitted in each case from the labelling of the segments. The sym-
bols in each bronchus indicate which segment it branches out to form. Each bronchial branch should be designated
by the name of the subdivision of the lung supplied by it.
VOL. 41, No. 2 Practical Correlative Anatomy of the Bronchial Tree and Lungs
For the lower lobe there is a rather large segment
occupying the upper or superior portion of the
lobe and there are, on the right side, four segments
making up the basal portion of the lobe. These
four segments have been named by their position
in the basal portion of the lobe - anterior, lateral,
posterior and medial basal segments.
On the left side, the upper lobe bronchus, as
has previously been stated, divides into two
branches, and therefore we have two larger subdi-
visions of the left upper lobe that correspond to
upper and middle lobes of the right side. Adams
and Davenport3 have suggested that these portions
of the left upper lobe might be called divisions to
differentiate them from the smaller subdivisions
which have been called segments. Following that
suggestion, Doctor Jackson and I have used the
names - upper division of the left upper lobe
and lower or lingular division of the left upper
lobe. The upper division of the left upper lobe
has two subdivisions which we have called apical-
posterior segment (which corresponds apparently
to a combination of the apical and posterior seg-
ments of the right upper lobe) and anterior
segment of the upper division of the left upper
lobe. When we come to the lower or lingular
division of the left upper lobe, we find the two
segments which make it up are related superiorly
and inferiorly to each other, and we have thus
designated them as superior and inferior segments
of the lower or lingular division of the left upper
lobe. In naming the segments of the left lower
lobe the same names are used to the extent possible
as those which are used on the right side, that is,
we name an upper or superior segment of the
left lower lobe and then name the basal segments
of the left lower lobe. However, the anterior and
medial basal segments are combined so that we
speak of an anterior-medial basal segment, a
RIGHT LUNG
LOBES SEGMENTS
Apical
Upper Posterior
Anterior
Middle
Midl Lateral
Medial
Superior
IMedial Basal
Lower Anterior Basal
Lateral Basal
---Posterior Basal
55
posterior basal segment, and a lateral basal segment
of the left lower lobe. The suggested names* can
be tabulated as listed below:
If one can agree upon names for the subdivisions
of the lung, then the problem of naming the bron-
chial branches is solved, because all that one has
to do is name the bronchus as bronchus to a named
portion of the lung, that is, we speak of upper,
middle, and lower lobar bronchi on the right, side,
and we speak of anterior, posterior, and apical
segmental bronchi which are branches of the right
upper lobe bronchus. We speak of medial and
lateral segmental branches of the middle lobe
bronchus and of superior, medial basal, anterior
basal, lateral basal, posterior basal segmental
branches of the right lower lobe bronchus.
On the left side we speak of upper lobe bronchus,
lower lobe bronchus, with the upper lobe bronchus
dividing into upper division bronchus, and lower
or lingular division bronchus. The segmental
branches of the upper division bronchus are the
anterior segmental bronchus, and apical-posterior
segmental bronchus. The segmental branches of
the lower or lingular division bronchus are the
superior segmental bronchus and inferior segmental
bronchus. To put those names in another form,
one can speak of the bronchus to the apical-posterior
segment of the upper division of the left upper
lobe, the bronchus to the anterior segment of the
upper division of the left upper lobe, the bronchus
to the superior segment of the lower or lingular
division of the left upper lobe, and the bronchus
to the inferior segment of the lower or lingular
* These names have now been approved by the American
Broncho-Esophagological Association and are used in
Gray's Anatomy (Twenty-fifth Edition), Morris'
Human Anatomy (Tenth Edition, Sixth Printing)
and Grant's Method of Anatomy in addition to the
places indicated in Table 1.
LEFT LUNG
LOBES SEGMENTS
Upper 5 Apical-posterior
Division 1 Anterior
Upper
1 Lower f Superior
(Lingular) t Inferior
Division
Superior
Anterior-medial
Lower Basal
Lateral Basal
Posterior Basal
56 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION MARCH, 1949

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58 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
division of the left upper lobe. The naming of the
segmental bronchi of the left lower lobe would
follow a similar plan and one would refer to
the bronchus to the superior segment of the left
lower lobe and the bronchi to anterior-medial basal
segment of the left lower lobe, lateral basal segment
of the left lower lobe, and posterior basal segment
of the left lower lobe.
There have been a good many sets of names
suggested particularly for the branches of the
bronchial tree. Some of these have been based
on the direction in which the branches are running,
others on the portion of lung to which the bronchus
is distributing. The segments have been named
either by the bronchus running to them or by
their position in the lung or by their relation to
structures outside of the lung, that is, by their
relation to other contents of thoracic cage or to
thoracic wall. There has been no other terminology
suggested which consistently names the segments
by their position in the lobes and then names the
bronchi according to segments to which they go.
It is beyond the scope of this discussion to take
up in detail other terminologies which have been
suggested and attempt to show wherein we feel
that the terminology which we have suggested is
more practical. Many of the names which have
been applied to the branches of the bronchial tree
by various authors are given in Table 1 and the
multiplicity of bases for naming will be apparent
at a glance.
Doctor Jackson and I have felt that there is a
definite advantage in naming the subdivisions of
the lung first and then allowing the bronchus to
be named according to the subdivision of the lung
to which it goes. We have also felt that there is a
real advantage in having a constant basis upon
which the naming of the subdivisions of the lung
can be based and since the basis, which has been
used for years in naming the lobes, is the position
of the lobe in the lung, we are carrying this basis
on by naming for left upper lobe the divisions by
their position in the lobe, and then for the other
lobes and for the divisions, the segments by their
position in the lobe or division, as the case may be.
This same basis can be carried as far as it becomes
necessary in the naming of increasingly smaller
portions of lung substance. If it is found necessary
to subdivide the segments as one can on the basis
of the distribution of the branches of the segmental
bronchi, then, one can name the subdivisions of the
segments by their position in the segment.
MARCH, 1949
VARIATION
By now I am sure the question has come to mind
as to the constancy of the pattern of bronchial
branching which has been described, and, therefore,
of course, the constancy of the subdivision of the
lobes of the lung as they have been described. The
chief point which I would like to make in this
connection is that the constancy of these descrip-
tions is definitely as great as for the majority of
anatomical structures; more constant than some,
less constant than others. They definitely are well
within the range of variation that one sees for any
of the described structures which are usually taken
to fit into a fairly standard pattern. Of course the
exact percentage of incidence of the various
arrangements that have been described would
depend a great deal on the degree of detail that
one is looking for. For example, if one examines
dissected specimens of the right upper lobe bron-
chus he finds that in about 90-95 percent of the
specimens it is possible to interpret this brochus as
having three segmental branches. There will be
instances in which it is a matter of interpretation
as to whether two of the three come from a very
short common stem. In other instances there will
definitely appear to be a common stem for two of
the three branches but, in most of the cases one
can feel reasonably sure that he is correctly inter-
preting the picture when he says that the three
segmental branches of the right upper lobe
bronchus are represented. It must, however, be
emphasized that if one not only studies the bron-
chial branching but also checks the distribution of
the branches* he will find that sometimes although
the branching looks like the usual pattern the
distribution of two of the branches isn't usual, one
bronchus distributing to a smaller portion of the
lobe than usual and the other to a larger portion
than usual. The probable explanation of this situa-
tion is that a bronchus which is ordinarily a branch
of one of the two segmental bronchi involved is
coming from the other one in this instance.
For the lower lobe bronchus, the constancy is
not quite as great for some of its branches. The
superior segmental bronchus and the medial basal
bronchus (on the right) are about as constant as
* Dr. Boyden and his associates are carrying out a series
of studies of variation by such a combined procedure.
The most recently published paper in this series is
"A study of variations of the bronchopulmonary seg-
ments of the right upper lobe" by J. G. Scannell and
E. A. Boyden, J. Thor. Surg., 17:232, 1948.
VOL. 41, No. 2 Practical Correlative Anatomy of the Bronchial Tree and Lungs
the situation given for the branching of the right
upper lobe bronchus. There is more variation in
the anterior, lateral and posterior basal bronchi and
their related segments. Perhaps one should mention
in discussing variation the fact that there are in
almost 50 per cent of the specimens branches which
come from the posterior aspect of the lower lobe
bronchus between the superior segmental bronchus
and the basal bronchi or from the stem below the
anterior basal bronchus. In the studies which we
have made this branching is found to be present
in less than 50 percent, and has, therefore, not been
included in the diagrammatic representation of
the usual pattern.
PRACTICAL IMPORTANCE
Before closing, it probably is worthwhile to
make some mention of the clinical importance of
this concept of bronchial branching and related
subdivision of the lung. The whole story means
so much more to the bronchoscopist than it could
otherwise if as he is seeing bronchial orifices, he is
able to immediately relate the orifice which he is
seeing to a definite portion of the lung, be it lobe,
division, or segment. Also, of course, the broncho-
scopist may be of help in locating a lung abscess
by finding pus coming out of one bronchial orifice,
under which circumstances he can be reasonably
sure of saying that the lung abscess is in the seg-
ment supplied by that bronchus.
For the radiologist this concept of the lung gives
a much more satisfactory way of locating pathology.
That is, he can specifically state in many instances
that there is pathology in one segment or another
which is a very accurate and easy way of locating
the lesion. In addition to that, it makes the under-
standing of the atelectatic shadows which appear
on the X-ray film much greater if one is aware of
the subdivision of the lung on the basis of bronchial
distribution. The radiologist can also, of course,
be of assistance to the bronchoscopist in telling
him the location of foreign bodies so that the bron-
choscopist will be able to locate the involved
bronchus more rapidly. From the standpoint of the
thoracic surgeon, it is interesting that at times
he can do a segmental resection rather than taking
an entire lobe when there is pathology, in the lung.
It may therefore be possible to save more normal
lung tissue than otherwise would be the case.
Another point that is not too well known and
must be very thoroughly studied before one can
be sure of its significance is the possibility of
59
predilection of disease for certain of the segments.
For example, the posterior segment of the upper
lobe is a favorite site for tuberculosis. Lung abscess
is quite apt to appear in the superior segment of
the lower lobe or in adjacent parts of the anterior
and posterior segments of the upper lobe, also in
the posterior basal segment. It is well known that
bronchiectasis quite commonly involves the lower
lobe, and in addition the adjacent part of the mid-
dle lobe on the right side, and the lower or lingular
division of the upper lobe on the left. It is possible
that pneumonia has a slight predilection for the
superior segment of the lower lobe.
The question of the predilection of disease for
certain segments is one of the many problems in
connection with the bronchial tree and lungs which
still require a great deal of study.
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des Menschen, Leipzig, Wilhelm Englemann, 1880.
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Brock, R. C.: The Anatomy of the Bronchial Tree,
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Churchill, Edward D. and Belsey, Ronald: Segmental
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de Pablo, V. E.: La Arquitectura Bronchopulmonar,
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Treatment of Yaws in the Haitian Peasant*
CHARLES R. REIN, M.D.
HAITI, the second smallest of the twenty-two
Latin-American republics, won its inde-
pendence from France in 1804, thereby founding
the second free state in the Western hemisphere,
and the first independent Negro state in the mod-
ern world. In an area of ten thousand square miles,
inhabited by approximately three million people,
there are less than 5000 Caucasians. Although
Haiti ranks thirteenth in population, it is first in
density of population in the entire Western Hemi-
sphere. The health of the Haitian people is con-
stantly threatened by a triad of diseases, malaria,
hookworm and yaws. Of these, yaws is the most
virulent and the commonest and was probably
brought over from Africa as early as 1509. When
this disease is untreated, it produces crippling
and loathsome disfigurement of its victims. Al-
though the entire West Indies group of islands
have endemic yaws, it is estimated that in Haiti
alone, approximately 80 percent of the rural popu-
lation is infected with this disease. Yet in spite
of the proximity of Haiti to the United States,
yaws is rarely encountered in this country. This
may be due to a number of factors: 1) Immigra-
Read before National Medical Association, August 19,
1948.
From the Department of Dermatology and Syphilology
of the New York University College of Medicine,
Dr. Frank C. Combes, Director.
MARCH, 1949
Neil, J. Hardie, Gilmour, W. and Gwyne, F. J.: The
Anatomy of the Bronchial Tree, Brit. Med. J., 1:495,
1939.
Nelson, H. P.: Postural Drainage of the Lungs, Brit.
Med. J., 2:251, 1934.
Overholt, Richard H. and Langer, Lazaro: A New
Technique for Pulmonary Segmental Resection, Surg.,
Gyn. and Obs., 84:257, 1947.
Peirce, Carleton B. and Stocking, Bruce W.: The
Roentgenological Anatomy of the Chest. II. The Bron-
chial Distribution, Amer. Rev. Tuberc., 39:516, 1939.
Rigler, Leo G.: The Chest. A Handbook of Roentgen
Diagnosis, Chicago, Year Book Publishers, Inc., 1946.
Rubin, Eli H.: Diseases of the Chest with Emphasis
on X-Ray Diagnosis. The Principles of Surgical Treat-
ment, by Morris Rubin, Philadelphia, Saunders, 1947.
Westermark, Nils: On Bronchostenosis, A Roentgeno-
logical Study, Acta Radiolog., 19:285, 1938.
tion from Haiti is exceedingly low, approximately
200 immigrants from Haiti were admitted to the
United States in 1947. This does not include
transient visitors. However, yaws is most prevalent
among the Haitian peasants and they seldom leave
their own country because of their limited finan-
cial status. 2) The United States Public Health
Service requires the Master of any incoming vessel
or airplane to report to the proper authorities any
immigrant who has a cutaneous eruption or fever.
Furthermore, all immigrants are subjected to a
physical examination prior to entry into this coun-
try. In this way most infected individuals would
be detected and detained. 3) It is the opinion of
most observers that the temperate climate of the
United States is not conducive for the propaga-
tion of yaws. Even if some individuals with this
disease escaped detection and were admitted to
this country it is quite possible that the active
manifestations would subside without specific
therapy and thus minimize its further spread.
There have been a few reports of cases of yaws
in this country and in 1922 Fox' reported on the
prevalence of this treponemal disease in the
United States. He reviewed all of the previously
reported cases and was of the opinion that the
condition was present in the southern states prior
to the Civil War. Since 1922 there have been addi-
tional reports in the literature of yaws in the