^p^ ^<.* y ^K \.y Public Health Is Purchasable. Within Natural Limitations Any ICommunity'ilCan Determine Its Own Death Rate MANUAL FOR PUBLIC HEALTH NURSES HERMANN M. BIGGS, M.D. Commissioner I NEW YORK STATE DE 1 '" AR ' 1 ' MLN1 OF HLAL TH ALBANY, N. Y 1920 ^ y CONTENTS Chapler ' I Public Health Nursing in New York State 5 ' II Sanitary Inspection 22 III Pure Milk Supplies 38 IV Pure Wat«r Supplies 50 V Disposal of Sewage 66 VI Control of Flies, Mosqutoes Other Insects and Vermin 87 ' VII The Nurse and Commun"cable Diseases 94 •VIII Public Health Nursing and Tubercu osis 106 IX Cooperation of Health and Educat onal Authorities in the Con- trol of Communicable Diseases 130 X The Public Health Laboratory 138 XI Laboratory Service 140 - XII The Nurse in Public Health Education 150 oor to pay or are too ignorant to follow directions. She can not only relieve the physicians of the burden of explaining the Public Health Xui^.slxg 15 nature of disease aud the methods of treatment to the ignorant, but she can persuade the careless and indifferent to persevere in scientific methods of treatment. It is not her place to make dis- tinctions between physicians but extend to all equal courtesy and resjject. If a person has a preference for any particular physician, it is the duty of the nurse to regard that prefer- ence. If she is loyal and helpful to all physicians alike she has a right to take an indigent patient in need of medical assistance to the physician whom the patient prefers and to receive free advice as to the condition and treatment of the case. Relation to relief organizations. A public health nurse should cooperate with relief officers and organizations, such as overseers and superintendents of the poor, societies for the prevention of cruelty to children, and for the prevention of blindness. Red Cross societies, charitalile organizations, and churches. She works with all these agencies, and is one of their principal representatives in lines of work affecting the health of persons who are unable to care for themselves. 8he refers cases to them, and secures their assistance in her own health work. Relation to the public. The relation of a public health nurse to the public is princi])ally that of an investigator, adviser and teacher. Her methods are those of persuasion and instruction rather than force. It is not within the scope of her work to issue orders or to make threats against offenders. If legal action or force is necessary, it nmst be applied ]>y the health officer, or liy the State Commissioner of Health. Work axd Activities Assignments. A public health nurse employed by the depart- ment of health of the state or of a city receives from time to time, usually in writing, special orders or assignments. If employed by a local health board the nurse may do any branch of public health work that occasion requires; but every such nurse is re- sponsible to the local health officer from whom she receives her assignments and to whom she is expected to report the results of her work. The Avork of a public health nurse may be classified as field and office work. Field ivorJc, Field notes, taken on the spot, arc an iiidi:.'!)?!!- li) State Depakt^mext of Heat.th sable part of all field work. Eveiy nurse should carry a note- book in which she can make records while doing her work. In investigating an outbreak of an epidemic of measles, scarlet fever or typhoid fever, for example, she should make her records at each house or place that she visits as she obtains her information, writing down the names and addresses of the cases and contacts, the dates of onset of illness, and all other facts or conditions which relate to the epidemic. This is absolutely neces- sary, not only because she can not tnist to memory for such details, but because the notebook is positive evidence of what she dis- covered by her investigation and will l)e accepted as such in law should the case come before the courts. Elinor items which would ordinarily be forgotten if not recorded, may also form clues which may lead to further important information or serve to confirm other facts, and if these are set do^vn in ■v\Titing they may be studied at leisure. Office luork. The routine office work of a public health nurse will usually be done along the following lines : (1) Reviewing, analyzing, arranging and tabulating her field notes ; (2) Formal reports; (3) Research work in the office files and library; (4) Correspondence; (5) Reading and study. A field notebook is a collection of items recorded in the order in vv^hich the information was obtained, without regard to arrange- ment. The notebook is intended for the use of the nurse only, and it should be preserved in its original form as confirmative evidence of the facts, should they be disputed: Imt the items require to be classified and arranged in such manner that the facts which they record are readily availal)le to others. To do this will take time which can not be spared in the field, where much of the Avork will be done. Ileuce it has to ho completed in the office. The State Department of ITenlth requires formal reports of nil work' dour by nurses in its employ. Similar reports shouki be recniircd of nurses employed by local boards of health or by private agencies. Such report should be transmitted through tbe local officer of the board of healtli. The preparation may require Public Health Nursing 17 more time than the field work which it represents. The report should be descriptive and statistical, giving a surmnary of the work done with its various items. It should give a clear, complete and concise review of the situation. It may begin with a short descrip- tion of the work and end with a statistical summary. The report must mention the assignment for doing the work and from whom it was received, and it must contain sufficient data to enable the reader to understand why, when, where and how the work was done and the reasons for doing it. If previous reports of the same conditions have been made they should be referred to in such a way that they may be easily identified. If an assignment of work requires several days to complete, a report of the progress of the work must be made daily. These daily reports may be so made that collectively they form the complete report. A nurse's work is constructive, not destructive; its object is not to criticize past mistakes but to improve future health conditions. If she finds, therefore, that work previously done by another is faulty, due to icTioraiK-p or incompetence, she mav report this to the Sta+o Department of Health, but she should avoid all local fault-finding and offer advice and assistance only to improve the conditions, without personal comment of any kind. A nurse is often required to do research work in looking up reports of work similar to hers and in reading articles on the sub- ject in books and periodicals in order that she may coordinate her report with that of other workers in the same field. Moreover, she should become familiar with what others are doing in her line of work so that, when written, her report will be a contribution to existing sanitarv^ information. A public health nurse is expected to devote some time to reading and study on all subjects relating to public health, on general subjects of information so that she may be prepared for any assignment, even though it be outside of her particular line of work. Opportunity should be given to attend conferences as provided for by law and special schools or courses of in- stniction, possibly at the expense of the municipality, private organization or industry by which she is employed if the benefits derived are likely to be commensurate with the expense involved. 18 State Department of Health A State Department of Health nurse -vvho is sent to a city or village should communicate first of all with the sanitary super- visor of the district, and with the local health officer. She should always do this even when assistance is not required. The sanitaiy supervisor and local henltli officer are entitled to ho infomied con- cerning ever^^ health activity in their district. The nurse and the lo.cal officials can always be of mutual assistance to each other and recognition of this fact will promote goodwill and cooperation. A public health nurse is expected to be able to conduct her own investigations independent of direct assistance ; she is not supposed to be dependent upon any local official for material assistance, transportation, or other personal help. If it is necessary to give a nurse assistance the assigning officer will arrange for the specific assistance to be given. At the same time it is the duty of every local health officer or i-egistrar to allow the nurse access to his official records and to give her any official information that she may require. Expenses. A public health nurse should be allowed necessars' traveling and hotel expenses while doing field work. She should be expected to use the ordinary public conveyances such as rail- roads, trolleys, bus lines and steamboats whenever possible and not to hire special conveyances unless no public conveyance is available. When unusual expense is incurred, she should obtain a receipt for it. Hours of duly. A public health nurse should be on duty from 9 o'clock A. iM. to 5 V. M., with an hour for lunch. If she is doing field work her hours will be irregular according to the character of her work. She may have to work all day and in the evening, as in securing cultures and specimens. She should devote sufficient time to the work in hand to accomplish it efficiently and ]>roin])tly. A ])ublic health nurse should not be expected to work on Sunday idthough in an emergency she may he nniuired to do so. Lines of work. The three great divisions of work in which public health nurses and all pu1>lic h(\',lth officials are engaged are: J (1) Sanitation; (2) Control of communicable diseases; and Public Health Nursing 19 C^ (3) General measures for the improvement of health and the prevention of disease. Sanitation. Sanitation is concerned with the environment of man and deals with the physical conditions outside of the l>ody aifecting the puhlic health, rather than with the individual him- self, which constitutes personal hygiene. Sanitation is the peculiar field of work of the sanitary engineer or inspector, and not of the health physician or nurse; but when no sanitary inspector is available, the public health nurse may be called upon to assist a health officer in making the annual sanitaiy survey of a district, as required by section 21-b of the public health law, or she may be assigned to make a formal sanitary inspection. This survey or inspection should take cog-nizance of and includtJ a report on the sanitary conditions of all buildings and premises, public or private, where a menace to health may exist ; and super- vision must be maintained to prevent the recurrence of insanitary conditions. The follo\^iiig conditions are to be specially investigated: ^(1) Food sanitation, including the milk supply and food sup- plies other than milk, to insure pure food supplies and the pre- vention of insanitary methods of handling; " (2) Water supplies, to insure pure supplies of water and the prevention of careless disposal of human excrement ; (3) Sewage and waste disposal; and (4) Breeding places for flies, mosquitoes and other insects and vermin. Control of communicahle diseases. The control of communi- cable diseases is related to man himself, and the disease germs Avhich grow within the human body far more than with man's environment. For supervision in the control of communicable diseases the public health nurse may be assigned to any or all of the following lines of w^ork: ''(1) Investigation of the modes and channels of infection; V (2) Discovery of unrecognized or unreported cases; - (3) Instruction of the public in measures to prevent further spread of infection; 20 State Department of Health • (4) Securing laboratory specimens for diagnostic purposes; v/ (5) Supervision of quarantine; (6) Cooperation of school and health authorities in the control of communicable diseases; (7) Cooperation with various charitable organizations for adequate hospital care of the sick and (8) Cooperation with other philanthropic agencies for pre- vention of needless distress in families under quarantine or other- wise disabled (as in tuberculosis) by the presence of disease. In milking investigations for the discovery of unreported cases the nurse may be required to prepare maps and charts to illustrate the facts in graphic form. She may also be requested to furnish material for the press in order to arouse public sentiment and thus assist in controlling the situation. ^ General measures. Eveiry constructive program for the improve- ment of health and the prevention of disease should be preceded by a preliminary study of the conditions present in a community which are inimical to health. For example, it would be obviously unnecessary to do extensive educational work for the reduction of infant mortality in a community which has a low infant death rate, or to devote much time and labor to propaganda for the prevention of tuberculosis in a district where comparatively few cases of this disease occur. Local conditions studied in advance must determine what work is needed. One may often learn from reports of other communities how certain results have been accom- plished. Communities, however, have their individualities just as persons have, and it is not always practicable to employ in one community the methods which have proved successful in another. Each community must be studied by itself. General measures for the improvement of health and the pre- vention of disease will include the following lines of work: (1) Public health education; (2) The study of vital statistics records; ■73) Infant welfare activities; (4) Supervision of midwives; Public Health Nuesing 21 (5) Control of commiinicahle disease, including tuberculosis and venereal disease; (6) Health supei-vision of the school child ; (7) Hygiene of home and workshop; and (8) Mental hygiene — prevention of insanity and mental defects. State Department of Health CHAPTER H Sanitary Inspection The public health nurse, in making a sanitary survey of a dis- trict, should carefully ohsen^e the surroundings of every locality which she visits, whether it be for the control of communicable disease, for the promotion of child welfare, or for some other pur- pose. She may also be assigned to the work of making a formal sanitary inspection. Dryness, sunlight and cleanliness are the keynotes of sanitation in the modern acceptation of the term. We now know that most disease germs do not grow and multiply in such environment. ]^ot all conditions which appear dirty or unsightly are necessarily dangerous to health, but on the other hand, apparently clean and sightly surroundings may not be sanitaiy. Almost all of the com- municable diseases are contracted through close personal contact with human beings, the greatest enemy to mankind 1)cing man himself. The chief importance of insanitary conditions due to the lower animals, to decaying vegetables and to dirt from inanimate sources, is that they may permit the breeding of flies, and other insects and vei-inin which may be the means of transmitting dis- ease germs of human origin and so indirectly cause the spread of infection. Most of the diseases of man, especially those which occur in epidemic form, are peculiar to human beings. Some of these infections may be communicated to the lower animals under experimental conditions, but they do not occur in them as a nile under natural conditions. Fonnerly sanitarians regarded the environment as the main source of infection ; but it has been found by experience that though this may be the modiuin of conveyance of disease it is not the source of infection. Wlicn a nurse mjikcs a sanitary inspection, therefore, she iiuisl look especially for con- ditions which are of human origin. The danger to health from human excretions arises fi"om the Public Heat.th Nursing 23 fact that disease gemis may be present in them. All human bein^jjs do not give off infectious organisms but only sick people or disease carriers ; the latter are persons who harbox germs of a certain disease without showing symptoms of it. Those who dis- charge disease germs constitute but a small proportion of the population. Many persons excrete these germs without knowing it and take no care of their excretions. For this reason it is ex- ti'emely difficult to control disease carriers. Any collection of human excretions may contain disease germs from an unsuspected sourse and therefore should be considered as suspicious or dan- gerous however small the amount. Millions of disease germs may be present in an infinitesimal quantity of excretion deposited on soiled hands. Even a single typhoid bacillus in milk may cause an epidemic, while a drop of intestinal excretion from a typhoid carrier may infect a household water supply. Insanitary conditions which produce disease may be few in a given community, but efforts should be made to abate all such conditions. One of the chief factors in increasing the danger from insanitary conditions is congestion of population. A single family living in the country, separated widely from other people and seldom receiving visitors, nins little chance of disease infec- tion, but if there are a hundred or more families in a group, or if a large number of persons are crowded upon a small area and the families live in cramped dwelling quarters, congestion favors the transmission of disease, especially if it is associated with poverty, ignorance, uncleanliness and low standards of living. Insanitary conditions, therefore, which may be comparatively harmless at an isolated farmhouse, become an actual menace to health in a village or city. As population increases the importance of sanitation grows at a relatively much more rapid rate. Urban or concen- trated populations present far greater sanitaiy problems than rural scattered populations. Insanitary surroundings affect health in direct proportion to the opportunity for contaminated substances to enter the body. The principal agents for the transmission of contaminated sub- stances are: (1) persons, by coming in contact with such sub- stances; (2) food; (3) flies; (4) drinking water. 24 State Department of Health Persons may transmit contamination from their hands, clothing and from various articles to other persons by personal contact, i^'ood and water even slightly contaminated are likely to produce disease because they are taken into the body in considerable quan- tity where the conditions are favorable for the growth and multi- plication of the disease genns. House flies breed in horse manure and human excrement and in fermented and putrefying vegetable matter, and they may contaminate food supplies by acting as mechanical carriers of infection. Decaying and putrefying vegetable matter, though offensive to the senses, is not necessarily dangerous unless it contains disease germs deposited in it from human sources. Decaying substances do not in themselves cause disease, although indirectly they may affect health by forming breeding places for flies. If a nurse is asked to make a sanitary inspection of occupied houses and premises she should begin by asking the owner, agent or occupant of the premises to accompany her or to give her per- mission to make the inspection. Although a health department nurse has a legal right to, inspect insanitaiy premises she should use diplomacy and tact rather than legal authority to achieve her object. If she is refused admission the fact should be reported immediately to her superior officer, but as a rule the nurse will be well received. She should confine her inspection strictly to the work in hand, the sanitary conditions which caused her inspection of private property, and make no comments about other matters. Conditions which a nurse is ordinarily requested to ob- serve arc: (1) general topography; (2) housing; (3) cleanli- ness; (4) household drainage; (5) disposal of human excrement; (6) garbage disposal; (7) barnyard conditions; (8) breeding places of flies, mosquitoes, etc.; (9) water supply; (10) milk supply; and (11) food handling. These are the most important conditions directly affecting health, though there are many others having little or no effect upon health which may be classed as nuisances and which are under the control of the department of health and also within the scope of inquiry by the sanitary inspector or nurse. General topography. This includes relation and reference to wells, bodies of water, woods, housas and other features of the Public Health Nursing 25 locality. The most important thing for the public health nurse to note is the soil in relation to household drainage; the slope of the ground surface in order to deteniiine the direction of the flow ; the nature of the soil, whether rocky, clayey or sandy, in order to observe its capacity to absoi-b and conduct the drainage ; and the character of the subsoil from which the private water supply is drawn. Housing. The next point to observe is the house in relation to the size of its living quarters and the number of persons occupying a room, in order to determine whether it is overcrowded or inade- quately ventilated. In connection with housing are to be con- sidered such conditions as darkness, dampness, cold and uncleanli- ness. Darkness is usually associated with dirt and dampness. A lack of sufficient windows will affect health. A house that is out of repair is often an indication of a low standard of living. The sensation of warmth or coldness will be a rough guide as to the temperature of a room, and the odor of the indoor air as to ventila- tion. Ventilation and heating are important factors in housing; and will be discussed later. Cleanliness. Cleanliness is the comer stone of sanitation. Cleanliness of rooms, furnishings and persons are most important points to observe in making a sanitary inspection. The sanitarian's conception of cleanliness of surroundings has greatly changed with the advance of knowledge as to the kinds of dirt, the degrees of dirtiness and the nature of these in relation to health. The modern standard of cleanliness is not physical or esthetic, but biological. The infection on household utensils or in water, milk, food or on other objects can not be seen, although the danger of such invisible dirt is known. It requires a bacteriologist to tell the difference between dean dirt and insanitary dirt. We must therefore insist upon scrupulous cleanliness and educate people to understand the biological meaning of this tei-m. Experi- ence has taught that cleanliness is the most efficient single means that we possess for protection against disease ; that clean surround- ings are apt to be free of infection; that olean food is apt to be safe food. This practically means that only dirt which is con- taminated with disease germs is dangerous to health. House dirt may contain disease organisms, especially that which has been 26 State Department of Health recently contaminated with human discharges. Drying usually kills most disease germs within a few hours, but the germs may be alive for some time in dust containing freshly dried excre- tions. Few bacteria will survive vigorous washing and cleansing such as a cleanly and careful housewife gives to her rooms and furniture. The public health nurse should therefor carry on a campaign for sanitaiy cleanliness just as the surgeon does for surgical cleanliness. Household drainage. The drainage from a household is an important item in every sanitary inspection. If the waste water is conducted into a sewer the nurse should obser\'e only the clean- liness of the plumbing, and take note of any suspicious leakage. If the house has plumbing which is connected with a cesspool she should inspect the latter to see whether it is properly covered and not overflowing. If the house has no plumbing she should observe whether or not the waste water from the kitchen and laundi-y is allowed to accumulate in pools near the house. Many houses in the country lack proper facilities for house drainage. The methods of disposal of household drainage are discussed in the chapter on the disposal of sewage (page 66). Disposal of human excrement. One of the most important items of sanitary inspection is the manner of disposal of human excreta. Particular note should be made as to the possibility of contamination of the water supply and as to the means taken to prevent the access of flies. The methods of disposal of human excrement are discussed in the chapter on the disposal of sewage (page 66.) Garbage disposal. Garbage consists of waste foods from the kitchen iiiul dining room; it is often mixed with paper waste, tin cans, etc. It seldom contains disease germs or is a direct menace to health. It is importajit, however, to the sanitarian because it readily undergoes fermentation and putrefaction ; and because it mny be the breeding place for flies and may attract vermin. The common methods of garbage disposal are: (1) feeding it to fowls and pigs, which is an economical method and more sanitai-y thnn if it were left to decay; (2) burial, either in the ground or in ;i manure pile, which is a sanitary method if the Public Health Nursing 27 garbage is covered to a depth sufficient to place it out of reach of flies; (3) incineration, which is the most sanitary of all methods when properly done; (4) reduction, or the recovery of fats and fertilizer which in some city garbage works pays for the collection. In noting the methods of garbage disposal the following con- ditions are to be reported by a public health nurse as unsatis- factory: (1) garbage heaps in the back yard ; (2) flies or fly larvae in the garbage; {?>) garbage containers out of repair, or not prop- erly cleaned; (4) absence of tight covers on the containers. Barnyard conditions. Barnyards come under the supervision of health officials only in so far as they directly or indirectly atfect health. In this sense they may be the breeding places for flies and mosquitoes, etc. ; they may hinder the production of pure milk ; they may be sources of water pollution ; and they may become har- boring places for rats and other vermin. They are not considered as direct sources of infection unless they are polluted with human excretions, but they may be contributory causes of disease and thus should be controlled by the health department. Fly control. A nurse who is making sanitary inspections should look for the breeding places of flies, especially during the summer months. These are usually found in manure piles, garbage heaps, stables, privies and other places in which decaying vegetable or animal mattei is deposited. Methods of fly control include the use of covered containers to prevent the access of flies to breeding places; the use of chemicals to destroy fly larvae and pupae in manure piles ; and mechanical methods of protection from flies, such as screening traps, fly paper, etc. The subject of fly control is discussed in the chapter on breeding places for flies and other insects (page 87). Mosquito extermination. ]\Iosquitoes breed in almost any col- lection of stagnant water, even though it be only a cupful or leas. The discovery that certain kinds of mosquitoes are necessar)^ to the completion of the life cycle of the organisms of malaria and yellow fever has made the control of their breeding places of great importance in localities where these diseases are prevalent. The annoyance caused by other kinds of mosquitoes which are not known to be disease carriers makes their extinction also very desirable. The same measures of extermination are effective against all varieties of mosquitoes. One of the most important 28 State Department of Health of these measures is the control of house drainage and rain water near dwellings. Any untreated <3ollection of stagnant water in the summer time should ]ye condemned on the ground that it may breed mosquitoes. The subject of mosquito extermination is discussed in chapter VI (page 89). Water supply. The source and character of the water supply is one of the most important items of sanitary inspection. A nurse should first inquire whether the supply is derived from a public or private source; if it is from a lake, stream, spring, open or driven well, or cistera. The character of the water may be best judged by an analysis of a sample and inspection of the sur- roundings and source. If there is evidence of contamination the well should be abandoned or the water from it boiled except that used for mechanical purposes. Public water supplies are under the control of the Division of Sanitaiy Engineering of the State Department of Health and their supervision is largely a technical problem, but a public health nurse may be required to assist in a sanitary inspection. The elementary principles involved in securing and maintaining a pure water supply are discussed in chapter IV (page 50). ilftZA: supply. The principal conditions pertaining to milk which affect health are: (1) the health of the cow; (2) the presence of barnyard dirt which may enter the milk; (3) the changes which the milk usually undergoes ; and (4) human disease germs, which may be introduced into the milk by the insanitary methods of those who handle it. From a sanitary standpoint the modern circumstances which tend to increase the danger from milk are: (1) large routes of collection and delivery by means of which an infection at any one dairy is spread through a distributing center to a great number of customers; (2) long periods of storage and transportation by which the age of milk before delivery is increased; (3) the larger number of persons who take part in handling it; (4) the custom of distributing milk in bottles which are collected after exposure to contamination in the household and the resultant work and care necessary in the cleaning of the bottles. To meet and solve the different problems of milk production Public Health Nursing 29 under these circumstances requires official supervision, and in addition the kind of popuhir education which a public health nurse is well fitted to give, A public health nurse may also be required at times to assist in inspecting aaid scoring a dairy. The sanitary principles involved in securing and maintaining a pure milk supply are discussed in chapter III (page 38). Food handling. A public health nurse may be called upon to inspect the methods of handling and storing food in houses, bakeries and at soda fountains, restaurants, markets, and other places where food is prepared and handled or sold. Food may become contaminated during handling either &om its environment or from the handlers themselves, the latter way being much more common. The principal points to be observed in the environment of food are: (1) the cleanliness of the room and con- tainers; (2) the exposure of the food to flies and dust; and (3) the temperature at which the food is kept. The main points to be noted in persons who handle food are : (1) cleanliness of hands and clothing; (2) health, especially as to the existence of colds, coughs, sore throat, diarrhea and other communicable diseases; and (3) possibility of the presence of healthy carriers of disease. The latter are usually impossible to detect without a systematic search being conducted by trained health officials and laboratory tests made on specimens of discharges obtained from such sus- pected persons. A nurse should also observe whether food is to be eaten raw or cooked, as raw food is always to be considered dangerous if handled by unclean persons or in unclean surround- ings. The heat of cooking usually destroys both disease germs and the bacteria of fermentation and decay. The nurse should not be deceived, however, by the cleanliness of the dining room or the attractiveness of the food on the table, but she should judge of the sanitary condition of the food in the storeroom and kitchen before it is cooked. Unclean cooks and kitchen equipment may infect food with disease germs which give no indication of their presence. The chief points to be observed in food handling in homes are: (1) general cleanliness of the kitchen, pantry and containers, and of persons who handle the food; (2) presence of flies on food and of vermin in the kitchen and pantry; (3) temperature at which food is kept. 30 State Department of Health Places of Public Assemblage Where Food is Prepared, Hai^^dled and Sold The handling of food is forbidden in certain cases by the State Sanitary Code (Chapter II, Eeguhition 39), as follows: "I^To per- sons affected with any communicable disease shall handle food or food products intended for sale which are likely to be consumed raw or liable to convey infective material, No person who resides, boards or lodges in a household where he comes in contact with any person affected with the bacillary dysentery, diphtheria, epidemic or septic sore throat, measles, paratyphoid fever, scarlet fever, poliomyelitis, acute anterior (infantile paralysis), or typhoid fever, shall handle food or food products intended for sale. No waiter, waitress, cook or other employee of a boarding house, hotel, restaurant, or other place where food is served, who is affected with any communicable disease, shall prepare, serve or handle food for others in any maimer whatsoever. No waiter, waitress, cook, or other employee of a boarding house, hotel, restaurant, or other place where food is served, who lodges or visits in a household where he comes in contact with any person affected with bacillary dysentery, diphtheria, epidemic or septic sore throat, measles, paratyphoid fever, scarlet fever, poliomyelitis, acute anterior (infantile paralysis), or typhoid fever shall pre- pare, serve or handle food for others in any manner whatsoever."' Since it is not practically possible to insure that employees in establishments where food is prepared, handled or sold are not carriers of disease, inspection here is the only safeguard against infection. During an epidemic or at any time that he sees fit, the health officer may detail the public health nurse to routine inspection of bakeries, soda-water fountains, restaurants, markets, and other places of public assemblage where food is prepared, handled or sold. In making an inspection of an eating house the nurse should note the date, street, number, name of o^vner and proprietor, address and business; whether foods are exposed to flies and other insects, dust or dirt ; whether the clothing of persons handling food is clean; and whether the business is conducted, in a cleanly manner, especially as to the methods and thoroughness of dish washing, and should give details. She should note the constniction Public Health Nursing 31 of the place where foods are sold or stored ; if water-closet and lavatory are provided ; if they are separate from the room where foods are sold or stored, and their condition ; if cuspidors are pro- vided and their condition, whether disinfectants are used ; and if the store or storeroom is used as a dormitory. She should inquire as to the health of persons handling food ; if they are in good health themselves ; if there is any illness in their families ; if there are cases of illness in persons who have been living or working on the premises but who have departed, their names, addresses and means of identification, and the extent of their contact with other persons to whom they might communicate the disease. When the facts point to infection of any particular place, the homes of cooks, waitresses and other employees should be visited. If the disease may be water-borne and the mode of infection has not been determined, the source of the water supplies should receive special attention, and in the case of a spring or well it should be inspected in order to discover whether it is liable to become contaminated. If bottled water is used the brand should be noted, and if communicable disease is present on the premises, whether the empty bottles are returned to the dealer, and what, if any, measures are taken to prevent possible spread of infection. The presence of dogs and cats, with possible opportunity to convey infection, should receive attention and record. If the disease may possibly be milk-borne the fullest details should be given concerning the source of the milk supply of both milk and ice cream, and the care of the milk and empty con- tainers used on the place. When communicable disease is present milk and ice cream containers must be sterilized by methods approved by the health officer before they are returned. When laboratory specimens are desired the nurse will be required to secure these during her visit and forward them at once to the laboratory, together with a detailed report (on a blank form fur- nished by the State Department of Health) containing specific information collected during the investigation. The instructions she gives should include suggestions regarding desirable changes to be made in methods and conditions, and the place should be subsequently inspected, when necessary, to see whether these conditions have been corrected. Revisits should 32 State Department of Health follow promptly when insanitary conditions are found, and be con- tinued at frequent intervals until they are found to be remedied. Persistence, tact and courtesy will remedy a large majority of insanitary conditions without resort to compulsion. In ijispection of bakeries imd confectioneries the above prin- ciples should be carried out, special attention being paid to cleanli- ness of habits and methods on the part of operators, and whether the bread and other food products are properly wrapped and pro- tected against handling, dirt, dust and flies during transportation and while on sale. At soda-fountains and other places where beverages are sold, the special points to be noted are cleanliness of methods, including proper washing of glasses and other utensils, and proper protec- tion from fly and dii't contamination. Such glasses are used many times a day and should be accordingly most strictly looked after. Particular attention should be given to the rims of the glasses which have been experimentally shown to harbor numerous germs ; after-washing in clean water is therefore important. At markets, especially those in which produce usually eaten without peeling, paring or cooking is sold, special atttention should be paid to fruits and vegetables, whether they are protected against flies and contamination while on display or in transporta- tion or storage, and whether they are kept on stands high enough above the ground to prevent the access of domestic animals. Food poisoning. The Sanitary Code requires (chapter II, regu- lation 41) that if a public health nurse learns of the occurrence of a number of cases of severe or fatal illness believed to have been due to the consumption of articles of food suspected to have been spoiled or poisonous, it shall be her duty to report the same immediately, by telephone or telegi-aph when practicable, to the State Commissioner of Health and to the local health officer in whose jurisdiction the cases occur. The Abatement of Nuisances Nuisances. A nurse is not expected to undertake the abatement of nuisances beyond the limit of what can be accomplished by advice and a])[)eal. But it is well within her province to make a thorough inspection of the premises, and if she finds any condi- Public Health N"ursing 33 tion of nuisance which she is not able to have corrected by friendly- advice or persuasion to report the case to the local health officer, who, as agent for the board of health upon whose action and direc- tion the case depends, will proceed with its abatement in accord- ance with the Public Health Law and the procedure given in chapter VI of the Sanitary Code. It is essential that the public health nurse bo familiar with the subject of nuisances and the manner in which they are abated, although the responsibility for their abatement rests upon the health officer and the board of health. Abatement. While the subject may be viewed from many angles, for practical reasons it will be helpful to look at it from only three, viz: classihcation of nuisances; statutory require- ments to be met ; procedure to be followed. In regard to classification, nuisances may be considered under various groupings, as, for instance, those prescribed by the Penal C/ode; or as major and minor nuisances; or with reference to nat- ure of the materials responsible for the nuisance, such a:s organic and inorganic; or with reference to the objects affected, such as a pollution of the air, soil or water. To the health offi(;ial, however, the most important and practical classification would include, first, those nuisances which directly affect healtii; second, those which only indirectly affect health; and, third, those which may l)e considered as more appropriately fall- ing under other municipal jurisdiction. These classes are obviously arranged in the order of their relative importance from the standpoint of health, though not necessarily in the proper order from other standpoints. The first of these three important classes referred to — viz., nuisances which directly affect health — will include such con- ditions as cause infection of water supplies ; infection of milk and other food supplies; the breeding of mosquitoes, flies and other infection carriers ; in fact any condition which may be the source or vehicle of transmission of disease germs. jSTuisances arising from such conditions are clearly of primary importance, and should be abated without question or hesitation, and strictly in accordance with the procedure laid down by the Public Health Law and the Sanitary Code. 2 34 State Department of Health The second class of nuisances, those which indirectly affect health, will include a variety of objectionable conditions which only in an indirect way may be associated with disease transmission, but which do offend the senses, disturb the digestion or nervous system, and in these and other ways indirectly affect health. Under this class may be cited odorous and unsightly piles of decaying vegetables, fruits and other organic but noninfectious materials; odors froni privies the contents of which may not be exposed or even accessible; obnoxious gases and fumes from chemical and other industrial plants; garbage and manure piles; dirty pig pens and fowl yards, etc. In all these cases and with the limitations stated, there is no direct opportunity for disease transmission. The effect upon the senses may be offensive and even sickening, but not productive of specific disease. In other words, these nuisances only indirectly affect health. JsTumerically, it is the largest class a health official has to deal with, but unfortunately it is the one of which the ordinary layman usually, but errone- ously, exaggerates the importance from the health standpoint. This kind of nuisance is frequently the most difficult for a health officer to dispose of, and it is one where he should err, if at all, on the side of safety in regard to the necessity for abatement. rie should not dismiss such a case from his mind or fail to act merely because it is not a direct menace to health. It is an actual nuisance from the standpoint of offensive odors, unsightliness, or of even ordinary decency, and he should have it promptly abated. Tactful discrimination, moral suasion and appeal to civic pride and justice will usually be sufficient to accomplish this. It is important to remember idso that in dealing with any case which may be scientifically questionable as to its effect upon health, the health officer cAn always fall back oii the argument or principle of its indirect effect, be it nausea, discomfort, lack of sleo}) or I'est, or the irritation and depression of the nervous sys- tem. In brief, the health officer should make up his mind, without prejudice, whether the case is one which upon its full merits should be abated, and then should procetnl with its abatement. If the case should go to court the judge will usually be on the health officer's side, for judges fortunately are gen(M-ally both hunuin and fair minded. Public Health JSTursing 3i5 The third class of nuisances referred to, — those which more appropriately fall under other municipal jurisdiction, — will include those cases which, though they may in some respects indirectly affect health, yet are of such a nature as to come wholly or in part under police or other authority. This class includes howling dogs and cats, blasting, motorboat and automobile ex- hausts, unsightly fire rains, powder magazines, dangerous exca- vations, etc. Even smoke nuisances are by some authorities con- sidered outside the province of health authorities, in large cities quite properly so-. Many of these have special smoke ordinances and special smoke inspection. In dealing with nuisances of this class the health officer usually finds it more effectual to turn them entirely over to the police or other proper authorities, or at least to act in cooperation with these officials. As to the question of statutory requirements, the principal thing to remember is that there are certain classes of nuisances which, owing to their scientific aspect, or their being outside the territory of local jurisdiction, concern more the State Department of Health than the local board of health; in particular those provisions of the law which cover sewage and industrial waste discharge and the abatement of violations of rules and regula- tions enacted by the State Commission of Health for the protec- tion of public water supplies from contamination. In all cases of sewage and waste discharge into streams, except perhaps indi- vidual house drains, the State Commissioner of Health has direct jurisdiction under Sections 76-84 of the Public Health Law. All such cases should be referred by the health officer to the State Department of Health for disposition. In the case of a private drain, where a local nuisance is created, the health officer obtains more prompt and effective results by considering it as falling under Class I or II and applying the corresponding procedure in its abatement. In cases of violation of water rules affecting public water sup- plies the special provisions of Sections 70-73 of the Public Health Law apply. These cases involve a very specific and complex pro- cedure for abatement. The health board is involved at only one stage of this procedure, and since the board must act in accord- ance with specific orders from the State Commissioner of Health, 36 State Department of Health the health officer should refrain from any action whatever until Buch explicit orders, which are always self-explanator}% are actu- ally issued. With these two exceptions then, the abatement of all nuisances which involve action by the local health officer will fall under Sections 21, 2G, 31 and 32 of the Public Health Lajw and Chaptei VI of the Sanitary Code; this brings up at once the final question, procedure. It is essential that the health nurse should read Chapter VI very carefully, for these sections provide not only the authority but the definite procedure which the health officer must follow in the abatement of all nuisances within his jurisdiction. It should be remembered that Sections 21, 26, 31 and 32 give full authority to investigate and abate nuisances and Chapter VI of the Sanitaiy Code outlines the definite pro- cedure to be followed. In the ordinary routine of abatement of nuisances it will, of course, only occasionally be necessary to resort to any formal pro- ceedings, since mere suggestions and advice, fortified perhaps by tact and diplomacy, will usually accomplish results without coer- cive means. If, however, the case is important, or appears in any way stubborn, the health officer should be notified and he will usually take the formal procedure outlined in Chapter VI of the Sanitary Code and follow it step liy step. This course will not only at once make a strong impression upon the offender, but it will protect the health officer from any embarrassment that may possibly arise from any subsequent court proceedings. Should a case be referred directly or on appeal to the State Department of Health, it will still fall under Chapter VI of the Sanitary Code and will usually be first referred ])ack to the healtli officer for action. If the health officer fails to act, or if the Com- missioner reverses the decision of the local health board, the Commissioner will probably issue an order under Section 26 of the Public Heidth Law which is enforceable In- mandamus pro- ceedings. It will be seen, therefore, that Chapter VI of the Sani- tary Code, furnishes a jjrocedure which is to Ix^ followed not alone by the health officer, but also by the State Conunissioner of Health ; Sections 1, 2 and 3 furnishing the procedure to be talcen by the health officer and health board in those cases which are disposed Public Health Nuksing S'Y of by the local health board without intervention of the State Department of Health; and sections 4, 5 and 6, the procedure by the local board and the State Commissioner of Health in cases which are referred to the Department directly, or on appeal. In dealing with nuisances, then, it is essential to know these pro- visions of the law thoroughly, and to follow them explicitly. There is one feature, however, in the application of these laws about which one should be cautious and that is in the application of forceful means in the abntement of a nuisance. Sections 31 and 32 of the Public Health Law empower the health officer to enter property and by forceful means to abate any nuisance. These means, however, are rarely resorted to except in extreme cases, if at all. The simpler and more effective method will nearly always be to take the case into court and impose a fine or secure an injunction or both. This method will avoid serious personal enmity, insure a fair trial and leave a more salubrious moral impression upon other possible offenders or upon the community at large, than where martial law, as it were, is declared and force- ful entry and possiljle destruction of property is resorted to. 38 State Department of Health CHAPTER III Pure Milk Supplies The Sanitary Code of the State of Xew York prohibits the sale of milk at retail without a written permit from the health officer of the municipality in which the milk is sold. This permit must be renewed annually. The health officer or his representative is required to make a yearly inspection of every dairy farm where milk is produced for sale at retail within his district, after receiv- ing an application for a permit, and to score such dairy farms on scorecards prescribed by the State Commissioner of Health. The health officer may accept at his discretion the inspection and scor- ing by the health officer or his representative of another munici- pality, including 'New York City. The regulations governing the production and sale of milk and milk products may be found in Chapter III of the Sanitary Code, and in various sections of the Agricultural Law (sections 30 to 104). It is improbable that a nurse would be assigned to regular inspection and scoring of dairies, but in the presence of an epi- demic of communicable disease she may be called upon to assist the local health officer in the inspection of all places offering milk for sale at retail. The public health nurse may be required also to make an investigation of conditions existing on some particular dairy farm or farms if an outbreak seems to be milk-borne, or to inspect dairies maintaining insanitary conditions. When making such investigations her duties will consist in verifying the state- ments of the producer that the regulations to be observed, if the milk is offered for sale, are being strictly carried out, and in certifying to the local health officer the conditions found, the methods of disposal of the discharges of sick persons, the oppor- tunities for flies to convey the infective agent of the disease to the milk supply, etc. She is also expected to give special instructions to the family as to methods of conducting the isolation period of a communicable disease in the home. The nurse may be assigned to go from house to house in certain districts during an ^epidemic, giving instructions to those who desire or need it, as to the proper method of caring for milk in the home. In the Public Health Nursing 39 summer or during the presence of an unusual amount of diarrheal disease among children this is very imj^ortant. When needed she should help the family construct a cheap ice box such as is described at the end of this chapter, and assure herself that con- tainers are sterilized before being returned to the retail dealers. 'No milk bottles should be peiinitted to leave a house while an inmate is ill of any communicable disease without sterilization by methods approved by the health officer. When searching for the source of typhoid fever apparently milk- borne, the nurse is required to visit farms or dealers to see if any ]xa-sous are ill with, or convalescent from, typhoid fever, or give a history of a previous attack of this disease, or of an illness sug- gesting but not recognized as an attack of typhoid fever. The nurse is also expected to inform herself concerning the existence of a milk station in the neighborhood which may be shipping milk to another municipality, in order to determine whether there is any possibility of that milk supply being contaminated. In order, therefore, to carry out these investigations and instruc- tions for the control and prevention of disease caused by milk, the public health nurse should be informed as to the principal facts upon which is based the production of a pure milk supply. Impure milk is perhaps responsible for more sickness and death than all other foo.ds combined. The reasons for this are: (1) bacteria grow well in milk; (2) of all foodstuffs milk is the most difficult to obtain, handle, transport and deliver in a clean, fresh and wholesome condition; (3) it is the most readily decomposable of foods; and (4) it is the only standard article of diet obtained from animals which is habituall}' consumed in its raw state. About 16 per cent of the average dietary in the United States con- sists of milk and milk products. Fresh milk products made from infected milk may be nearly, if not quite, as dangerous as the milk itself. Milk, properly modified, is a perfect food for the suckling and is so largely used as food by adults as well as infants that there is every reason to encourage the production of pure milk and to discourage and prevent the marketing of impure milk. Quality of milk. The qualities by which milk is judged are its freshness, purity, cleanliness and wholesomeness. Milk is said to be fresh when its condition and composition are the same as when 40 State Depaetment of Health it was drawn from the cow. Milk is pure when it is fresh and clean, that is, when its condition and composition are unchanged and it is not contaminated with foreig7i substances. When milk is fresh, pure and clean it is wholesome. Bacteria in milk. Milk as it comes from a healthy cow is usually wholesome, but it readily undergoes changes, due princi- pally to the action of bacteria which enter the milk after it is drawn from the cow. that render it unwholesome. The bacteria ordinarily found in milk are: (1) those producing lactic acid; (2) those causing femientation and putrefaction; (3) the germs of human disease; and (4) beneficial and inert bacteria. Lactic acid bacteria decompose sugar, changing it to lactic acid which is a harmless product. The bacteria of putrefaction change proteins to sul>stances which may be detrimental t(i health, especially in infants. The genns of human diseases if introduced into milk may live and multiply, producing the dis- ease of which they are the infectious agents in those Avho drink the milk. Not all bacteria are harmful. Some produce beneficial changes in milk, such as those which give the agreeable flavors to butter and cheese ; others bring about no apparent changes in milk or its products. Impaired quality in milk is chiefly due to the following changes: (1) souring or lactic acid fennentation ; (2) coagulation or curd- ling; (3) unpleasant taster and odors; and (4) the presence of bacteria in excess. Souring is the most common change which takes place in milk and is due to lactic acid bacteria. Sometimes when milk or cream is ke[)t too long, even at a temperature which prevents souring, putrefactive changes may occur which will render it unfit for food. Coagulation is produced when a considerable quantity of lactic acid is present in milk the lactic acid uniting with the phosphates wliich hold t]i(> protein in solution, so that a semi-solid curd or casein is furnicd. Milk nuiy b<> curdled also by artificial fer- ments such as rennet. Curdled milk obtained from clea^n milk, if kej)t under clean conditions, is a wholesome food. Public Health Nursing 41 8limy or ropy mill'. Certain bacteria growing in milk may produce mucilaginous substances. The entire milk product of a dairy has been known to become viscid in this way. Though such milk is considered a delicacy in some countries, in this country it is not so regarded. It is not injurious, however, from a standpoint of health, unless it is slimy as a result of diseased conditions in the mammary glands. Thin and watery milk is produced at times by bacteria yielding ferments that dissolve and decompose proteins. The products of this decomposition are often harmful. Tastes and odors. Unpleasant tastes and odors in milk are usually caused by: (1) dirt in the milk; (2) certain foods of cows, like turnips or wild garlic; (3) the action of bacteria causing fermentation and decay. Tastes and odor due to food may be reduced or removed by the process of aeration when the milk is run in a thin film over the cooler. Unpleasant tastes are often evidence of the presence of harmful bacteria. The harmful effects caused by milk used as food are produced either by unwholesome chemical compounds developed in the milk, or by human disease germs introduced into it. Chemical products affect health within a few hours after the milk is taken into the body. Sickness caused by disease germs in milk does not develop until the expiration of the period of incubation of the disease, — that is to say, from a few days to a week or more, during which time many persons may become infected. Disease germs rarely if ever produce changes in milk which are recognizable, and the first manifestation of their presence is usually the development of the disease in a number of persons who have been using the same milk. Under these circumstances the milk should be held under suspicion and an investigation made to determine the cause. Investigation of the qiudity of a milk supply is always required when tracing the origin of an epidemic. Bacterial count. Almost all of the harmful effects due to milk are the result of bacterial action. One of the most reliable indica- tions of the quality of milk is the number of bacteria present in each cubic centimeter. This number is estimated by a bacterial count which is the basis upon which milk is usually graded by boards of health. All milk contains some bacteria — the best 42 State Department of Health milk on the market a few thousands, ordinary milk hundreds of thousands, and poor milk millions of bacteria in each cubic centi- meter. A sample of milk for a bacterial analysis is taken in a sterilized container which holds about half an ounce. The milk is first stiiTed or shaken thoroughly in order to distribute the bacteria uniformlj'. The bottle is then nearly filled and aseptically sealed, th(^ container is surrounded with ice to prevent the bacteria from growing and is forwarded pi'omptly to a labo.ratoiy as soon as possible. A bacterial count does not indicate the total number of bacteria present in a sample of milk, but only the number of bac- teria that will develop colonies in the culture medium employed, and at the temperature and within the given period of incubation. The standard methods of counting are those which have been adopted by the American Public Health Association, experience having shown that these methods give the most uniform results and afford a fairly reliable indication of the quality of the milk. Adulteration of milk. The common adulterations of milk are: (1) skimming; (2) watering; (3) thickening agents, coloring matter, alkalies, sweet substances; and (4) chemical preservatives. Skimming or removal of part or all of the cream and selling the balance as whole milk is fraud but has no reference to health, except that the milk is lowered thereby in nutritive value. Adding skimmed milk is also a form of adulteration often difficult to detect. Watering milk, if the water be pure, is also to be regarded more as a fraud than a health problem. The addition of water to milk lowers its specific gravity, raises its freezing point and also lowers its viscosity. Thickening agents such as challv, calves' brains or glycerine are not commonly used. Coloring matter, such as annate (a vegetable dye) is sometimes added to milk with the object of concealing skimming or watering, or to make tlio milk look richer. Alkalis, such as sodium carbonate or l)icarboiiate, are occasionally added to milk to reduce its acidity or to dchiy curdling. Sweet sul)stances, such as saccharine and sugar, are sometimes added to milk either to raise its specific gravity and thns disguise watering or to disguise the sour Public Health Nursing 43 taste of milk just on the turn. Chemical preservatives, such as borax and boric acid, salicylic acid, benzoic acid and benzoin, peroxide of hydrogen, formaldehyde, etc., have been used in milk. No satisfactory chemical preservative for milk has been dis- covered which will kill the bacteria or prevent their growth with- out injuring the milk. Almost all states and countries prohibit the use of such foreign substances. Dirty mill: — the dirt test. Practically all milk contains some dirt. Milk that contains visible dirt nearly always has a high bacterial count. A rough test for visible dirt is to observe the sedi- ment deposited on the bottom of a milk bottle or other container. The presence of dirt may be more accurately determined by the sediment test, which consists in filtering a pint of milk through a little disc of absorbent cotton. This leaves a stain varying in intensity from a yellowish to a brownish or black spot. A good crucible, a Lorenz apparatus, or simply an ordinary funnel may be used to filter the milk. Ordinaiy milk will usually leave a con- siderable number of visible specks of dirt in the cup. Warm milk filters more rapidly than cold milk. The sediment test is one of the most practical of the routine tests used for the public health control of milk supplies. It may he made use of in educating farmers and dairymen as well as consumers regarding the relation of cleanliness to the wholesomeness of milk. The discs may be dried and kept with the records of the dairy in the health of&ce. Milk that has been " clarified " or strained of course will not show a sediment. Composition. The composition of milk is exceedingly complex. It consists chiefly of wate]% several proteins in suspension, fats in emulsion, sugar and a number of inorganic salts in solution ; also ferments as well as antibodies, cells, gases, etc. The market value of milk depends upon the quantity as well as the quality of its various food elements, particularly protein, fat and sugar. The percentage of these three elements are of special importance in calculating the diet of infants. Experience has shown that reliable results are obtained when the percentage of cow's milk is taken to be 3.5 per cent protein, 4 per cent fat and 5 per cent sugar. Since milk varies in composition, minimum standards have been set by law. The standard of New York State is that milk shall con- 44 State Department of Health tain at least 3 per cent of fat and 11.5 per cent of total solids. The sale of milk below this standard of composition is illegal (Agricultural Law, section 30). Test for fat. There is accurate test for the amount of fat which is known as the " Babcock Test." It depends upon the fact that sulphuric acid added to milk acts upon the protein and liberates; the fat, wliich then floats on the mixture when its amount may be measured. Specific gravity test for adulteration. Milk containing the legal amount of fat and solids will have a specific gravity of 1.030 to 1.034. The specific gravity test is usually made with a special bulb called the " lactometer," but an ordinai-y urino-meter may be used. Fat being lighter than the rest of the milk if it is removed the specific gravity of the skimmed milk will be more than 1.034. The addition of water to milk lowers the specific gravity below 1.030. A specific gravity of more than 1.034 thus indicates that the milk has been skimmed, while a specific gravity below 1.030 indicates that it has been watered. Taking the specific gravity of the whole milk does not of itself detect either skimming or watering, since if these practices are done artfully, the specific gravity of the milk may remain unchanged. If these are suspected, therefore, from the appearance of the milk, further laboratory tests are required. Total solids. The laboratory test for the determination of total solids is by evaporation and direct weighing of the dried residue. Wholesome mill\ The four main conditions which must be observed in the production of wholesome milk are: (1) that it be taken from healthy cows; (2) that it be handled by healthy dairy- men; (3) that it be produced by clean methods; and (4) that it be pre3erved as nearly as possible in its original state of purity. Diseases spread hy milk. The diseases most commonly spread by milk are: tuberculosis, typhoid fever, diphtheria, scarlet fever. se])tie sore throat, malta fever and foot and mouth disease, also some of the summer com])laints of children and the diarrheal and dysenteric disesiscs • ndulls. Tlieso are often traceable to infected milk. Diseases of animal ori-gin. As a I'ule milk becomes infected from human sources, sometimes on the farm, sometimes at the Public Health Nursing 45 dairy, sometimes in transportation and occasionally in the house- hold. Not infrequently the milk becomes infected as a result of disease of the cow, as in the case of bovine tuberculosis. Bovine tuberculosis. This is the most common disease which may be transmitted from cows to human beings. Children, it is now known, are particularly susceptible to the bovine type of tubercle bacillus while adults are not. The principal organs which are affected with this form of tuberculosis are the lymph glands of the neck and the abdominal organs, the lungs, the bones and joints. Tuberculosis is so common among cows that sometimes nearly all animals in a herd are infected. The disease may be recognized in cows by three methods: (1) physical examination; (2) finding tubercle bacilli in the excretions; and (3) by the tuberculin test. Every cow found to be tuberculous is to be considered as a possible menace to pu])lic health. The laws of New York State require that all cows known to be tuberculous shall either be killed or kept under conditions prescribed by the State Commissioner of Agri- culture. (Agricultural Law, section 94.) It is a very difficult matter to discover tubercle bacilli in milk. The measures resorted to in oixler to secure a milk supply free from living tubercle bacilli are as follows: (1) the detection of tuberculous cows and their exclusion from the herd; (2) cleanly methods of milk production; and (3) the pasteurization of all milk. The latter is the only method upon which complete reliance can be pla€ed. Diseases of human origin spread hy milk. Milk is a culture medium favorable to the growth of disease germs. Cases of milk- borne disease frequently occur singly or in epidemic form, depend- ing upon the number of persons using the infected milk. The germs are usually conveyed to the milk by those who handle it, and the source of the infection is either the discharges from the nose and throat of such persons in coughing or sneezing, or the dairyman's hands soiled with these discharges or with the excre- tions from the intestines of the cattle. Milk-bome epidemics of diphtheria, scarlet fever and septic sore throat are common. The communicable diseases mentioned in the Sanitary Code of New York State as being likely to be transmitted by milk am: 46 • State Depaktment of Health diphtheria, septic sore throat, amebic or bacillary dysentery, epi- demic cerebrospinal meningitis, scarlet fever, smallpox, typhoid fever, paratyphoid fever, acnte anterior poliomyelitis and cholera. When a case of one of those diseases occurs on a farm or dairy producing milk or milk products, the code specifies that no milk or daily products shall be sold or delivered unless the conditions required are observed, or a permit be issued by the local health officer allowing the food to be sold or delivered. As a preventive measure an efficient inspection service strikes at the root of the milk problem. But inspection h:is its limitations; it can not detect disease carriers or mild cases of diseases, and inspectors can not be on hnnd at all places ;it all times. An essential factor of a successful inspection is the scorecard system. The scorecard system. The common standard by which the wholesomeness of milk is judged is the bacterial count. A low bacterial count is dependent upon the exclusion of dirt from the milk and cleanliness in eveiy stage of its production. The sources of dirt and bacteria in any given milk supply can only be dis- covered by a careful inspection of the dairy and close observation of the methods which are followed in handling the milk. The points to be noted in making such inspection are indicated on the official scorecards which have been adopted by various depart- ments of health. The scorecard should be used in inspecting dairies, but dairy scores are an imperfect means of judging the quality of the milk produced as determined by bacteriological tests. The omission of a single sanitary measure such as clean- ing the udder of a cow may cause the milk to have a high bacterial couni even though the total score of the dairy may be good. The principle upon which scoring is based is that of cleanliness of ever)'thing surrounding the milk, including dairymen, cows, stables, milk room and utensils. Pasteurization. The measures taken for the production of milk with low bacterial count are: (1) preventing bacteria from enter- ing the milk; (2) preventing bacteria from growing and multiply- ing in milk; and (8) killing the bacteria in the milk. The meas- ures adopted for preventing bacteria from entering the milk have already been referred to. The only practical method of killing Public Health ISTursing 47 bacteria in milk is the application of heat; the prevention of their growth and multiplication is effected by the application of cold. Milk may be preserved by boiling as in the canning of fruits and vegetables. This is the process used in making condensed or evaporated milk ; but boiling and evaporation changes the composition and taste of milk. It is preferable to sterilize the milk without changing it to any extent. The process of pasteuriza- tion does this by the application of a low degree of heat for a con- siderable length of time. The standard of pasteurization adopted by the 'New York Slate Department of Health is the exposure of milk to a temperature of 142°-145° F. for not less than 30 minutes. This degree of temperature and period of time are suffi- cient to kill pathogenic bacteria as well as those which are peculiar to the intestinal tracts of cows without changing the composition and taste of milk. Immediate rapid chilling of the milk to 50° F. or lower is essential. One test of efficiency in pasteurizing is a comparison of the bacterial count before and after pasteuriz- ing. Another test is the absence of colon bacilli in the pasteur- ized milk, for colon bacilli derived from manure are usually present in all raw commercial milk. When a milk-borne epidemic breaks out it may become necessary to pasteurize an entire milk supply to make it safe for use. An emergency method of pasteurization is to place the cans in a tank of boiling water, stirring the milk continually to distribute the heat, testing with a thermometer, and removing the cans when the temperature reaches 14^5° F. If the cans are placed in a warm loom the temperature of the milk will be retained at about 140 '^ F. for half an hour. Prompt cooling should follow. The home pasteurization of milk is sometimes desirable when infant food is to be prepared, or a milk-borne epidemic is threat- ened. For this purpose the milk may be heated in a double- boiler, stirred until its temperature by the thermometer reaches 145° F. and then placed on the back of the stove, where it remains at 140° F. for 30 minutes, after which it should be projnpth cooled. To correct any possible tendency to rickets in children fed exclusively on pasteurized milk, orange juice is given. Cooling milk The only practical method of restraining the 48 State Department of Health growth and multiplication of hacteria in milk is by cooling the wiilk as soon as possible after it is drawn from the cow and keeping it cool during storage and transportation. Milk is commonly cooled by allowing it to run in a thiji film over a cooler con- taining cold water or ice. A flat cooler enclosed in a case is preferable to the cone-shaped container often used, as the latter is liable to. become contaminated with dust or flies. A method of cooling milk frequently adopted on farms and at small dairies is to place the cans in cold spring water. The purity of the water in such cases is of great importance, as some of it may enter the can. Gradhig milk. Milk is graded by its quality and not by its composition. The grades are determined by scoring the dairy or by a bacterial count, or sometimes by a combination of both methods. The grades of milk which are recognized by the New York Stat-e Department of Health and the basis of the grading are given in the Sanitary Code of the State (chapter III, reg. 13). Permits. Permits issued by a health officer are required for the sale of milk in this State. These pei'mits are issued after an appli- cation has been filed with the health officer by the dealer and every dairy from which his milk is obtained is inspected by the health officer or his representative. While the system of permits does not insure a pure milk supply, it affords a means by which unsatisfactory dealers may be controlled and both consumers and producers may be educated in matters regarding wholesome milk. Procedures with suspected milk. Should a sample of milk be suspected to be unwholesome and be brought to the attention of a public health nurse, she may adopt the following procedures: (1) inspect the conditions under which the milk has been kept after delivery, since changes may have been brought about in the milk by conditions for which the buyer or consumer is responsible, such as time and temperature of storing, the manner of storage, etc. ; (2) place the sample in plenty of ice and send or take it at once to a laboratory for examination, stating the condition under which the sample was obtained; (3) trace the milk to the dealer and dairyman, and ascertain the conditions under which it was pro- duced and delivered ; (4) keep a detailed record of all information obtained and report it to the health officer. Public Health Nursing 49 The iceless ice box. A refrigerator without the use of ice can be conveniently constructed by enveloping a screened set of shelves in a canton-flannel jacket which can be buttoned around it and kept moistened by wicks of the same material placed in a pan of water on top of the box, moisture from the pan being allowed to drip on the sides of the box and keep the enveloping flannel moistened — as shown in the drawing. The evaporation of this A Box of screened shelveB. B Pan of water on top of box. C Pan beneath box for drippinga. D Canton-flannel jacket kept moistened by wicks of same material. Iceless Refrioeratok moisture will, in a relatively dry climate, maintain a temperature of about 50° F.* in the ice box and make the use of ice unneces- sary or help to preserve ice that may be used. Keep in a shady place, where the air circulates freely. * While this temperature is not low enough for prolonged storage, it is suflficient to keep food and milk for a short time, as is often done in a cool cellar. 50 State Depaktment of Health CHAPTER IV Pure Water Supplies The securing of pure water supplies for human use constitutes a specialty in engineering, but a public health nurse may be called upon to assist in the work. If in his judg-ment it is desirable a health officer may utilize the services of a nurse employed by the board of health in the investigation of specific instances of sus- pected pollution of water supplies. Such instances will probably be confined to the investigation of conditions surrounding farm- houses, shacks and temporary colonies of people where typhoid fever; dysentery or other water-borne diseases may be communi- cated through careless disposal of human excrement, or where a carrier may be suspected or known to be found. The nurse may thus be exp(>cted to report on the location and number of cases of the disease or of knoAvn or suspected carriers, the method of the disposal of their excrement and present an accurate description of the conditions which suggest possible contamination of the water supply. This repoii; might well include a sketch or map sliowing the location of wells and springs, streams and other sources of the water supply, and their distance from and relation to the place where the contaminating agent is deposited. It is essential, therefore, that the public health nurse should know what a pure water supply is and how to recognize it, and for this reason she should be familiar with the rudimentary principles which control the production of pure water on the one hand, and with the simpler methods of sewage disposal on the other. Pure water. The importance of having pure water in the home is axiomatic. Public water supplies are usually beyond the scope and ability of the nurse to control, but in small or rural com- munities where public water supplies do not exist, or where, if they do exist in part, recourse is often had to wells and springs for drinking purposes because the water is colder, it becomes of great value to the public health nurse to have some definite knowl- edge of the principles governing the securing of pure water, as the pollution of these sources is common and can often be remedied by comparatively simple means. Public Heai.th Kubsing 51 The quantity of water which is used in a household varies according to circumstances. Five gallons of water per person daily is considered to be a very small amount in a household that has no plumbing. If a house is provided with running water, a bath room and flush toilet, at least twenty-five gallons per person will be used daily for all purposes. In cities the quantity of water supplied is from seventy-live to three hundred gallons daily per capita. The term " pure water " as applied to water supplies is difficult to define in a strictly scientific manner. To all intents and pur- poses a pure water is one the use of which for drinking purposes will promote health rather than cause disease. A water to be pure and suitable for potable purposes should be clear, colorless, odor- less, palatable, and free from metallic poisons and from disease germs. The only water which approaches chemical purity is that which has been freshly distilled. All so-called pure waters contain a con- siderable amount of substances dissolved in them, such as gases and minerals of various kinds. The substances that are found dis- solved or held in suspension in water may be harmless foreign substances or dangerous impurities. A foreign substance which is harmful or objectionable is called an impurity. Hard water. Hard water is that in which a considerable amount of lime or magnesia is dissolved. These minerals do not make the water unwholesome, but they are objectionable in house- hold water, as soap docs not lather well in such water, forming insoluble compounds with the salts of lime and magnesium, which float as a scum on the surface or become entangled with the meshes of the cloth in washing. Hard water is thus not desirable for bath or laundry purposes. Water which contains 50 parts or more per million of hardness is usually classed as hard. Hardness in water is of two kinds, temporary and permanent. The lime or calcium carbonate is much more soluble in the presence of cai-bon dioxide and when a water containing lime held in solution by carbon dioxide is boiled the lime is precipitated out, due to the driving ofi^ of the carbon dioxide. The hardness thus driven out of solution by boiling is called temporary, while the remainder is called permanent. 52 State Department of Health Iron. Iron in a water supply is frequently derived from minerals in the soil, but it is sometimes due to corrosion of water pipes. Iron is not unwholesome in water, but if present in any considerable quantity (one part or more of iron in one million of water), it renders the water undesirable for bath or laundry work. One remedy for iron in water is to allow the water to stand in the tank or reservoir for some hours, and then drain off the clear water on top without the sediment. When Avater contains a large proportion of iron, a micro- organism called crenothrix may grow in it and form a jelly-like coating inside of the pipes and tanks. Pieces of this growth may break off and float in the water, or may die and impart to it an unpleasant taste or odor, or may form a scumlike oil on the surface of the water. It is, however, harmless to health. Irnpiirifies. Impurities in water may be divided into those which make it unsafe for internal use, as in drinking and cooking, and those which render it unfit for exteraal use, as for bathing and laundrying, cleaning, etc. A public health nurse is mostly inter- ested in the unsafe impurities which are found in drinking water, as these have direct effect on health. It is unsafe, how- ever, to use an impure water for any purpose in a household, as there is always a risk of some of the water getting into the mouth. Water that is discolored, or cloudy, or deposits a sediment, or has an unpleasant taste or odor, should be regarded with suspicion and as unsafe to use, unless it has been proved to be safe. At the same time, not all water that is apparently clean, bright and sparkling, is safe as such water may contain invisible germs of disease. Again, impurities may be classified according to their character into physical, chemical and bacteriological impurities. Physical impurities are those which are suspended in water, such as iron rust, particles of clay and mud, shreds of wood, leaves, etc., the presence of which is indicated by the turbidity of the water. They are themselves seldom harmful to health, but their presence is an indication that harmful substances may also be present. Chemical impurities are those which are dissolved in water, such as mineral impurities, partially decomposed organic matter and ptomaines, etc., produced during the process of decay. Mineral matter in water seldom affects health except in the case of metallic poisons. Public Health Kuesing 53 such as lead. Organic matter in water and the products of its decomposition are rarely harmful in themselves unless the water is grossly polluted with them. Of all impurities found in water by far the most important in relation to their effect on health are bacteria. Water can cause disease only when living bacteria of disease or some metallic poison are present in it. These bacteria are so minute as to be invisible and the clearness of the water is therefore no indication that they may not be present. The chief diseases which may be transmitted to human beings by means of water containing bacteria are typhoid fever, para- typhoid fever, dysentery and cholera. Tubercle bacilli and rarely found in a water supply, but their existence is possible if the water is grossly polluted from a case of tuberculosis. The principal impurities in water to be guarded against from a public health standpoint are the excretions of human beings, especially of persons who give off disease germs. The harmful impurities include sewage, household drainage, the contents of cesspools and privies, and other collections of matter containing human excretions. Detection of impui'ities. Impurities in water are detected: (1) by a sanitary inspection of the source of the water and its environ- ment; (2) by a chemical analysis; and (3) by a bacteriological analysis. All of these methods must be applied in order to form an accurate judgment of any given water supply. The omission of any one of them may lead to a false conclusion. A public health nurse, in making a sanitary survey of the source of a water should inspect: (1) the source itself; (2) the method of collecting and distributing the water; and (3) the presence of sewage and other human pollution, such as cesspools and household drainage. Water supply. Water supplies may be classified according to their sources into (1) rain water; (2) surface water, as that from streams and lakes; and (3) underground water from wells and springs. Each source of supply has its own particular problems for solution. Rain water. Rain water is usually collected from roofs and stored in underground cisterns. Theoretically, water as it falls through the air contains the least amount of foreign matter of all natural waters. Cisterns often contain coiLsiderable amounts of 54 State Department of Health foreign matter, however, the sources of which are for the most part : (1) dust and bacteria from the air; (2) dust, dirt and excre- ment of birds from the roofs of houses; (3) dust and dirt enter- ing through the covers of cisterns; (4) substances dissolved from the masonry of the cistern. The remedy for dust and dirt coming from the air and collecting roofs is to discard the first water which falls during a shower and to collect only that which falls after the roofs have been washed off. A simple device may be attached to the main conductors by which the water may be turnes 6 -h- -m: Deto//^ S/?oyy//?^ Mef/jocf of T/Z/n^ Fig. 5 Showing Arrangement and Details of Subsurface Irrigation System —Gentle Sloping Ground 78 State Department of Health failures, is to have the open joints properly protected. These joints are designed to peiinit the outflow of sewage effluent into the soil, but if they are not properly protected they may permit the adjacent soil to wash or sift in through them and cause obstruc- tions, if not fill up the pipe. It is very necessary, therefore, to have the top of each joint covered as shown in detail in Figure 5, preferably with a strip of heavy tar paper about 4 inches wide and extending over the top and well down on the sides of each joint, but not entirely encircling it. Another important detail in connection with this system is the arrangement of the different lines of pipe where the slope of the land is somewhat steep. One system is to have a main distrib- uting line run down the steep slope and the branch lines lead from it along level contour lines. Another and perhaps better plan is to omit the main distributing pipe altogether and lay out the entire system in one or two continuous lines with a series of short steep and long gentle slopes. The line would first run down the steep slope to the next lower contour then turn and run along this contour line with a gentle slope to the opposite end of the field ; then turn a right angle and run down the steep slope to the next lower contour and so on. A third and perhaps the best plan is to have the different lines of tile each provided with its independent distributor, each distributor leading from a common diverting manhole. Each line thus receives its independent and propor- tional share of the dose, and there is thus a uniform distribution over the entire field without surcharging at any point. There are a number of methods of sewage disposal other than the ordinary cesspool and subsurface irrigation system, such as sand filtration, contact beds and sprinkling filters; but while applicable to large serwerage systems for villages and cities, they meet the requirement of the country home for these methods all (Icinjind special knowledgo and skill to constnict, involve the final discbarge of an effluent into some watercourse, and to be successful need not only more intelligent but more skilled supei-- vision that is ordinarily available at the country home. The ordinary cesspool or a series of leaching cesspools installed with the precaution above pointed out will usually meet all require- ments demanded in the contry ; and where the cesspool is sufficient there will be few cases indeed where the subsurface irrigation Public Health Nuesing 79 >-^. D/Sfribufor hufo Defa/h' of D/'t^erfz/JS /y?an/7ofe for B B2E £>eta/ls of O/t^ert/ns^ A7a/7frof^ for C Fig. 6 Showing Arrangements and Details of Subsurface Irrigation System — Steep Sloping Ground 80 State Department of Health system will not prove adequate. ]Sreither of these methods in- volves an effluent to be finally disposed of into some watercourse, and both are more sanitary, self-maintaining, and, when properly installed, require less attention than the more elaborate methods applicable to village and city conditions. Disposal of Sewage of Institution and Municipalities In considering the disposal of sewage of institutions and munic- ipalities it will be assumed that the sewage has been collected in a system of intercepting and outfall sewers which conduct it to a suitable point for sewage disposal. In order to understand the methods by which such sewage can be properly disposed of it will be well first to consider the composition of the sewage which in American communities usually contains from 400 to 500 parts per million of solid ingredients, this being equivalent to about one^ twentieth of one per cent. Of these solids, about two-thirds are found to be in suspension and about one-third in solution. Again, of the suspended solids about two-thirds are organic matter and one-third mineral matter ; while of the dissolved solids about one-third is organic matter and two-thirds mineral matter. It is in fact this small amount of organic matter, less than five one-hundredths of 1 per cent, which gives to this class of sewage its objectionable qualities find renders it at times difficult of purification. When sewage of this character is discharged upon land, or into a body of water, it becomes objectionable, usually in one of three ways. It may, in the first place, become objectionable in appear- ance, due to the floating or fine suspended matters present in the sewage. These matters tend to form unsightly deposits upon the bed and banks of a stream, and to interfere in many ways with the industrial or pleasure purposes for which a stream may be used. This objectionable feature, while affecting mainly the esthetic quality for a stream, and only those persons or industries that actually use the water, does not in itself affect public health. In the second place sewage may become offensive as a I'osult of a diffusion of gases resulting when decomposition is carried to the point of putrefaction. Although this feature affects the comfort of those living along or in the vicinity of a stream, the Public Health Nursing 81 most careful investigation fails to reveal that it has any serious effect in producing specific diseases. Finally, sewage may become objectionable through the dan- gerous ingredients contained in it, which affect the health of human beings. These are the pathogenic or disease-producing bacteria frequently present in the sewage. They enter it from a variety of sources such, for instance, as from human discharges. Generally speaking, any method of sewage disposal for an insti- tution or small community must have for its object the fulfill- ment of one or all of the following requirements, viz., to remove the coarse and fine suspended matter, to prevent offensiveness to the body of water or land into or upon which the sewage is dis- charged, and to render harmless the disease germs contained in the sewage. The extent to which these requirements must be ful- filled in any case will depend upon the volume, the character and the uses made of the stream into which the sewage is to be dis- charged. Although there are no set rules that can be strictly adhered to, the following generalizations are made with respect to such requirements: First, where a stream is not subsequently used for a public water supply, but where its esthetic or industrial qualities are important, and where the volume of flow is so large, as compared with the volume of sewage, that offensiveness will not result, it will be only necessary to remove the suspended or floating matters by eflBcient screening or settlement. Secondly, where a stream is not used subsequently for a public water supply, but where the volume of sewage discharged into it compared with the volume of flow is so large that offensive odors may arise^ it will be necessary, in addition to the removal of sus- pended matters, to remove or oxidize the organic matter in the sewage. This can only be done by means of sewage purification and the effluents under these conditions must be what is termed stable, i. e., purified to such a degree that it will not of itself, or when discharged into the stream, subsequently putrefy. Finally, where a stream is to be subsequently used for a water supply not adequately protected by water purification it may be necessary to remove all substances from the sewage, including the bacteria. 82 State Department of Health Where a community is favorably situated with reference to a large body of flowing water the method of dilution becomes a satisfactoiy one. If, however, it is not so favorably situated or if the sewage must enter a stream or river which is subsequently used as a source of water supply, or if it is discharged into tidal waters in proximity to oyster beds this method must be abandoned in favor of some method of artificial purification. Of these artificial methods perhaps none is more effective than that of filtration, or the slow percolation of the sewage through beds of porous soil or sand. This method has been used for more than a century. It is in fact nature's method of purifying dirty water, which after rains flows over the surface of the ground, descends slowly through the pores of the earth, and finally issues as pure spring water. This method of filtration has been very thoroughly studied for many years in this countiy and abroad and it is now possible to foretell within narrow limits how much sewage of a certain com- position can be successfully purified when the quality and the size of the sand grains are known. Generally speaking, an acre of good effective sand can be so arranged as to purify indefinitely the sewage of about 1,000 persons. If the sand is coarse and deep, or the sewage has received some preliminary treatment to remove the suspended matters, a still larger amount of sewage can be treated. If the sand is fine, or mixed with loam or clay, this amount must be correspondingly decreased, reaching almost nothing for soils composed mostly or wholly of clay. Tt is usual to arrange sewage filters in beds or units of a definite size with the surface nearly level to insure a uniform distribution of the sewage. Beneath the surface at a depth of a few feet is laid a system of collecting pipes or underdrains. The sewage is applied in turn to each of the beds, and after percolatino slowly through them is collected in the system of underdrains and discharged into the nearest watercourse. When beds of porous material are not available or land is ex[)ensive it is frequently found more economical to purify sewage by some other method than sand filtration. Of these methods chemical precipitation has been satisfactorily practiced in the past, and although this process has given way to more economical and effective ways it is still used in many places. Public Health Nursing 83 By this method the sewage is passed tlirough tanks after It has been treated with certain chemicals such as lime or salts of alumina and iron. The sewage may be passed slowly through the tanks at a uniform low velocity, or the tanks may be filled, allowed to stand for a period of time and then discharged. In either case the chemicals unite with certain constituents in the sewage and form a coagulum which settles to the bottom of the tanks, carry- ing with it and precipitating upon the bottom the suspended mat- ters in the sewage. The relatively clear effluent is then passed off and discharged into the nearest watercourse or subjected to further treatment. This method of disposal at the present time is not considered a complete one in itself, but is practiced as such in some places and is frequently employed as a preliminary treatment. The difficulty of disposing of the sludge, the high cost of chemicals and the low purification effected make this method, however, a comparatively expensive one, and its field of usefulness restricted to peculiar local conditions or to the disposal of certain classes of trade wastes. Of greater utility than the chemical precipitation tank is the so-called septic tank. The origin of this appurtenance in sewage disposal is our well-known cesspool. In fact the septic tank may be considered nothing more than a large cesspool, scientifically constructed and operated, so that the highest biological efficiency is attained. If, then, through a long and narrow tank domestic sewage is allowed to pass, certain results are obtained depending upon the rate at which the sewage flows. When this rate is rela- tively high, i. e., if the period of detention in the tanks is less than about four hours, a mere settling or sedimentation of the sewage results — a merely mechanical result with no appreciable biologi- cal action. When this rate of flow is lessened, however, and the detention period increased to about eight hours, entirely dif- ferent results are secured. Instead of mere mechanic;il sub- sid'nr-e there is in addition a bacterial or septic action which produces marked changes in the organic mntter. The biological processes carried on in the septic tank are rather complicated. They are also quite variable in activity depending upon many factors such as the composition and age of the sewage, its temperature, the period of detention and the velocity of flow 84 State Department of Health through the tank. The process may be briefly described as one in which decomposition is allowed to continue until the sewage putrefies. The bacteria, working under anerobic conditions, are able to break down the more complex and unstable organic com- pouiidy and coiivort tlieiii into simpler and more stable ones. This conversion results in a liquefaction of portions of the suspended organic matters and a liberation of certain gases, such as sul- phuretted hydrogen, marsh gas and ammonia. The portion of the suspended organic matters not liquefied either rises to the surface to form a scum over the liquid in the tank, or settles, together with the mineral suspended matter not previously removed by settling or screening to the bottom of the tank in the form of sludge. Tliis sludge must be removed from time to time and disposed of by special treatment. The septic tank thus fulfills a two-fold object, removal by subsidence of a considerable portion of the suspended organic and mineral matters and the decomposition and liquefaction of a large part of the suspended organic matter. The organic matter thus converted is in a condition which many believe to be better suited to subsequent oxidation and nitrification than is the case with the raw sewage. And whatever may be said against the eco- nomic value of the septic tank, there is little question but that ]>roperly septicized sewage is more easily treated than either raw sewage or sewage that has been subjected to plain or chemical precipitation, and that the septic tank will continue to be a useful preliminary device in sewage disposal for many years to come. The treatment of either settled or septic sewage is usually accomplished by means of sand filtration, previously described, or by means of coarse grained or rapid filters. Of the latter class of filters there are two general types; the contact bed and the sprinkling filter. Although both are composed of the same materials — a mixture of coarse stone, gravel or coke — and are usually laid out in beds or units, their construction and operation are somewhat different. The contact l)ed is uPually constructed as a tank in which the filtering material of graded sizes is deposited with the coarser material at the bottom. The sewage is run onto the bed until it is full and is allowed to stand in contact with the filtering material Public Health Nursing 85 for a definite period of time. During this interval, and under the conditions of an ample supply of oxygen, the organic matter is rap- idly acted upon by the aei'obic bacteria until it is oxidized or nitrified, i. e., subjected to the last chemical change or action in the process of decomposition. At the expiration of this time period, ranging usually from two to four hours, the purified liquid is drained from the bed and discharged into the nearest stream, or subjected to further treatment. With the sprinkling iilter the constniction is almost identical with that of the contact bed, except that the walls surrounding t]:e filter may be omitted. The sewage is, however, applied in a very different way. Instead of flooding the filtering material the sewage is distributed through nozzles over the beds in the form of sprayed and allowed to percolate through them to the under- drains beneath. In this way a better opportunity is aiforded for aeration and nitrification, and results show that not only is the bacterial efficiency of the sprinkling filter higher than that of the contact bed, but that, owing to the better opportunities for oxida- tion, a larger volume of sewage can be purified per unit volume of filtering material. The effluents from both contact and sprinkling filters, though stable in themselves, and generally of satisfactoiy quality to be discharged into any watercourse, are, however, not entirely free from suspended matters. Fine and sometimes rather coarse particles of the film or coating attached to the stones of the filters, which form harboring places for the bacteria while performing their work of nitrification, become dislodged and are carried into the effluent. These particles are mostly stable, inert matter, rela- tively coarse and henv}- and subside quickly when the velocity of the effluent is checked. When it is desirable then to remove this suspended matter and to secure a clear effluent, it is only necessary to pass the effluent through a set [ling tank of moderate size and allow the suspended matter to settle out. Again, we find that the effluents from these rapid filters are not entirely free from bacteria and in some cases they show a very incomplete removal. These bacteria are in a large measure car- ried into the effluent along with the other suspended matters just described, and are probably of the harmless variety of nitrifying 86 State Department of Health bacteria that have developed either in the septic tank or in the filter. It is also probable that many of them are of the pathogenic species originally present in the sewage, so that there may be cases where it is desirable or imperative to remove not only the suspended matter but also the Ijacteria. When this standard of purity is demanded it becomes necessary to resort to supplemen- tary treatment either along lines practiced for the purification of water, such as mechanical or slow sand filtration, or by some method of sterilization. The disinfection of a sewage effluent or of raw sewage is gen- erally accomplished by the application of chloride of lime or chlo- rine gas. In either case after the disinfectant is applied the sewage or effluent is usually passed through a small detention tank holding from 10 to 20 minutes flow in order to afford oppor- tunity and time for the chemical to act upon and kill the bacteria. If chloride of lime is used it is first made into a solution and the solution is applied to the sewage uniformly in proportion to the flow. If chlorine gas is used it is usually applied directly to the sewage or effluent through a diffuser from cylinders of chlorine which contain the gas in liquid form under pressure. In applying the gas it is generally passed through a regulating device which automatically permits of its application at unifonn rates pro- portional to the flow of the sewage. Only small amounts are required for disinfection, ranging from 5 to 25 parts of free chlorine per million parts by weight of sewage or sewage effluent, the larger amounts being used for raw sewage and the smaller for sewage effluents. Public Health Nursing 87 CHAPTER VI Control of Flies, Mosquitoes Other Insects and Vermin It has been proved by scientific experiments that flies are active factors in the transmission of disease; that the female anopheles mosquito is an essential factor for the spread of malaria; that bubonic plague is a chronic disease in rats, the internal parasite of which is conveyed to humans through the bite of the flea; and that the body louse is the intermediary host in the transmission of typhus fever. The control of the fly, mosquito and rat through attack upon their breeding places and food supply, and measures for the complete destruction of the louse, have thus become an integral part of any comprehensive sanitary program which may fall within the province of the public health nurse. The fly. Studies of typhoid fever in the United States Army camps in 1898, and later in the city of Jacksonville, and the study of diarrheal diseases of infants made in New York City in 1915, have clearly demonstrated that the presence of the fly with access to human excrement and other discharges or food supplies increases the prevalence of these diseases. The campaign for the control of the fly involves (a) prevention of fly breeding and (b) prevention of flies having access to human beings and to their food. In the supervision of communicable disease, or in a sanitary survey looking to prevent conditions which are factors in causing disease, the nurse may be called upon to make a survey of all privies in the community, noting overflow, failure to screen or other insanitary conditions which permit access of flies to the excrement, and of places where are found manure or other refuse matter in which flies are wont to breed. The practical methods of controlling the spread of disease by flies fall under four main headings: (1) The prevention of the breeding of the fly by the elimina- tion of its breeding places. This requires the proper care of stable manure and the removal or disinfection of all decomposing refuse such as garbage, wet papers and rubbish of all sorts. The treat- ment of manure and other refuse with chemical disinfectants for 88 State Department of Health the prevention of fly breeding is a new development of the last few years and progress has been rapid. Borax has proved much more satisfactoiy than the substances previously used, and now the United States Department of Agriculture recommends helle- bore as even better than borax. (2) The control of breeding places must usually be supple- mented by the trapping of adult flies. A simple and effective trap may be made from a grocery box by substituting wire netting for the top and two sides, cutting a round hole in the bottomand insert- ing in it a wire cone with an eight inch opening at the bottom and a half-inch opening at the top. A suitable bait, a fish head for example, may be placed under the box and the flies which seek it will fly from it up toward the light and through the small top opening into the box. Dead flies may be shaken out through a small opening ordinarily closed by a sliding door. (3) The measures suggested above will greatly reduce the number of tlies but are not likely to do away with them entirely. As long as any flies at all are about it is essential to keep them from human excrement where they may pick up the germs of typhoid fever and similar diseases. Privy vaults should there- fore be most carefully constructed to exclude flies. The dis- charges should be received in a tight receptacle and all openings for ventilation, etc., should be screened with wire or cloth mos- quito netting and all cracks in the walls or openings under the bottom should be closed. (4) Finally, the doors and windows of houses should be screened, especially in the kitchen and dining room, in the nursery and any room in which there is a case of sickness. Care should be taken to see that the screens fit accurately and that they are always in place and that screen doors are not left ajar or kept open. If wire screen can not be afforded flies may be kept out by cotton mosquito netting tacked over the windows. Flies that do get into the house should be killed or should be caught in a saucer of water containing formalin, sugar and water. Fish and meat markets and restaurant kitchens should be equipped with fly traps. Ten thousand flies have been caught in throe days at such places. If there are clouds of flies in the market or the dining rooms or if foods exposed for sale are unpr> Public Health Cursing 89 tected against flies, the wise customer will go elsewhere with his patronage. The anopheles mosquito. The presence of the female anopheles mosquito is requisite for the spread of malaria. To determine if a given case is one of malaria it is necessary to submit a smear of the patient's blood for laboratory examination for the demonstra- tion of the presence or absence of the malarial parasite. The practical control of malaria consists in destruction of breeding places of the anopheles mosquito, the capture of the adult insect, thoroughly screening the sick person from a visit of the female anopheles mosquito and medical treatment of the malarial patient. In order to determine if the larvae of the anopheles are present in a locality the nurse may be required to collect specimens of water from places where they might be expected to breed. For this work she should be provided with a canvas or other bag or satchel, a small dipper with long handle, a teaspoon, and several small vials with stoppers. The larvae are found in the sedges and other vegetation bordering ponds, puddles, ditches and streams, generally in clean, clear water, sometimes in streams with con- siderable current, rarely in cans and rain barrels unless some vege- tation is present, rarely in sewage-polluted streams, but often in hollows in logs, footprints of animals in the fields, and even in cups and basins formed by large broad leaves and pitcher-shaped plants. The ova of the anopheles mosquito float on the surface of the water and are grouped in a pattern not unlike the meshes of a fish-net; the ova of the culex variety also float, but they are grouped together in the form of a little raft. The larva of the anopheles is much the most sensitive of the mosquito larvae, hiding when disturbed by sounds or even shadows, but coming to the surface for air. It may be distinguished from the larva of the culex in that it floats horizontally to and just under the surface of the water, while the culex larva suspends itself at an angle to the surface, tail up and head dovm, into the water. It requires from 9 to 16 days for the transformation from ovum to mosquito, and somewhat longer if the weather is cool. Some practice and much patience will be needed before the nurse will become skilled in collecting larvae. 90 State Department of Health For sociirijig specimens and for capture of the adult mosquito several large test tubes with rubber bands soaked in chloroform in the bottom of the tube should be used ; the mosquito is trapped in the tube, the chloroform quickly acts and a pledget of cotton secures her for examination. The anopheles mosquito may be identified while resting, by the fact that the body from head to tail is in a straight line and at an angle of about forty degrees to the surface on which it is resting. The culex mosquito has a bend or flexion at the thorax which causes the head to point toward the surface on which it is resting, the body being almost parallel thereto. To destroy its breeding places, weeds, sedges and grass should be cut and cleared from all possible haunts of the mosquito. It may be found necessary to burn out the vegetation bordering the puddles and ditches. The ponds and streams should be stocked with small minnows which eat the larvae and the surface of the water should be oiled. For this latter purpose Chapin estimates the required amount to be an ounce of crude petroleum to 15 square feet of surface, the oiling to be repeated regularly every 7 to l-i days during the breeding season. A lamp wick or piece of waste loosely placed in a hole in a keg of oil will make a satisfactory applicator, which may be managed from a small boat. For puddles, ditches and trenches, it will be necessary to use a spray. Systematic search of houses for the adult mosquito should be made, as the insects hide in closets, in the cellar and under the beds. The female anopheles which has never had access to a person with malaria is unable to communicate the disease. When the anopheles mosquito is present, all carriers and cases of malaria should be carefully screened in such manner that no mosquito can bite them. In Panama it was found that the flight of the anopheles at times exceeds one mile from the breeding place. The rat. Since the report by the Indian Plague Commission, the work of which was begun in 1905, it has been recognized that, as a factor in international sanitation, destruction of the rat should receive general attention. In the State of IS^ew York under present conditions the nurse's part will consist in teaching, where necessary, the method of extermination to be used by householders. In cities, where wharves and large grain elevators exist, rats become very numerous. If the food supply is removed the rats Public Health Nursing 91 will migrate; therefore, the first essential is that all refuse which may serve as food shall be promptly placed in metal containers with tightly fitting covers, and that it shall not be spilled on the floor or ground. If rats are present, all foods should be kept in rat-proof closets or storerooms. Concrete, metal and stout close mesh wire screens should be used for the purpose. Careless handling and spilling of food must be avoided. Cleaning up the premises, removal of rubbish, sanitary disposal of garbage, and trapping the rats, in addition to the other measures named, will rid the place of their presence.* For vessels lying at a rat- infested dock the hawsers which tie the boat to the shore should be freshly tarred and protected with inverted cones. Gang planks should be lifted when not in use. If rats are in a vessel it should be disinfected with sulphur dioxide and the dead animals sub- sequently removed and destroyed, care being taken not to touch the animals with unprotected hands. f The louse. Three species of lice are sometimes found upon man : {l)Pediculus capitis or humanus, the head louse, the ova of which are attached to the hair and known as nits; (2) Pediculus vesti- menti or corporis, the clothes or body louse, which lives in the clothing and sucks the blood chiefly of the neck, back and abdo- men; and (3) Pediculus pubis or crab louse, found in the parts of the body covered with short hairs. Both the head and body lice may transmit disease. They are known to be the intermediary host in typhus fever, and recently it has been demonstrated that the so-called " trench fever " of the soldiers in Europe is conveyed by the louse. . The prevention of lousiness is almost entirely a matter of per- sonal cleanliness. The most scrupulous individuals, however, may become infested. Lice may be passed directly from one person to another, or occasionally may be carried by clothes or other means. Beds in hotels and sleeping cars are sources of infestation. To destroy head lice. Saturate the hair with crude petroleum or kerosene, being careful of proximity to fire. Tie up the head for several hours, after which saturate with vinegar and again tie up the hair for a short time in a bathing cap or cloth turban. * Cats are also helpful; while they do not destroy all the rats, they aid in driving them off the premises. t See, The Rat and Its Relation to Health. Issued by the U. S. Public Health Service. 92 State Department of Health Wash and dry the hair ; remove the dead insects with a fine tooth comb and the eggs with the fingers. Examine the head daily and use a fine tooth comb. The petroleum must be used every second day in bad cases. To be efficacious the heads of other members of the family and of associates must receive suitable attention and treatment. All school children should learn to use preventive care. To destroy body lice. Bathe frequently with warm water and soap, boil infested garments, burn filthy bedding and clothing which can not be boiled, clean and renovate beds and infested quarters. Studies recently made under the United States Public Health Service have resulted in the adoption of a method of treat- ing persons by means of a gasoline soap spray and shower bath, and of treating clothing and baggage with a vacuum hydrocyanic gas process. Both lice and nits are killed by heating to 158° F. for ten minutes. Dry heat is more effective than moist heat. Per- haps the best substance to anoint the skin with is an ointment made of 5 per cent naphthalin in petroleum. The bed bug. This insect has become a true domesticated ani- mal and has accommodated itself well to the environments of human habitations. It has no wings but a very flat body which enables it to hide in the narrowest cracks and crevices of beds and walls. It is nocturnal in its habits. The presence of bed bugs in a house is not necessarily an indication of uncleanliness or care- lessness. They are apt to get into trunks of travelers or may be introduced in the homes upon the clothing of servants, workmen, etc. They often migrate from one house to another. They thrive particularly in old houses which are full of cracks and places in which they can conceal themselves. Bed bugs are suspected hosts and carriers of disease. The most effective way of eradicating bed bugs is by a liberal applica- tion of gasoline, kerosene, or any other of the petroleum oils. Gasoline is the best remedy when no danger from explosion from an open fire is present. It should be sprayed into crevices of the wood or metal, folds and cracks of the mattress, furniture and walls. In treating metal and hard wood, sometimes gasoline or alcohol may be poured in small amounts into the cracks and then ignited, but this should never be done except by someone with suffi- cient care and judgment to prevent danger from fire. At times Public Health Nursing 93 furniture is so infested with the bugs that it will be necessary to destroy it to get rid of the pests. At other times thorough renova- tion of the premises is sufficient. The itch mite. All children who make a practice of scratching themselves or have an irritation of the skin should be examined for scabies (the itch mite). A clean body and clean clothes are the preventive measures. A daily bath in warm water and soap, and once daily boiling the garments worn next to the skin, are impera- tive in the treatment of scabies. A sulphur or other ointment, if prescribed by a physician in charge, may be applied after the bath. It is important that all infested members of the family be treated until cured, else the disease is passed back and forth from one to another. Interchange of body linen among children and others must be prohibited unless the garments are first boiled. The infested person should not share the crib, pillow and bed of one not having the disease. Unless strict obedience to instructions and perseverance are secured, cases will prove obstinate. 94 State Department of Health CHAPTER VII The Nurse and Communicable Diseases Most large cities now employ one or more nurses who, working under the direction of the health officer, devote their entire time to assisting in the control of communicable diseases other than tuberculosis. In smaller communities the same nurse may in addition devote time intermittently to other important activities including child welfare, school work and cai^e of tuberculosis, the amount of time given to each depending on season, occurrence of communicable disease outbreaks and other local conditions. There are open to health officials two distinct courses of pro- cedure with reference to communicable diseases; the first, that of attemjjting to control epidemics, the other the more modern and effective method, that of preventing them. The prevention of outbreaks requires initiative, constant vigilance, and an adequate force of trained workers who are kept informed as to the latest advances in knowledge of methods and procedure. The most effective aid to a competent health officer in this work is an active, experienced and tactful public health nurse. The nurse may be called upon to perform any or all of several duties along this line. She may seek unreported or undiscovered cases ; visit rq^orted cases and contacts, secure necessary data for record or tabulation and study, give instructions to attendants or members of the family regarding care of the patient, disposal of discharges and other necessai*y precautions; arrange for care and relief of needy patients and families or supervise quai-antiue. She should not be authorized, for obvious reasons, to pass upon or con- firm diagnoses of attending physicians. In the absence of a school nurse she may make regular inspections of school children when communicable diseases are prevailing and visit absentees in their homes. Whatever her duties, she should maintain a systematic record of work performed. Whatever her other qualifications the public health nurse must cultivate diplomacy. Coming in contact in an official capacity, as she does, with public officials, physicians and members of Public Health ISTursing 95 families in every walk of life, success in her work will depend in large measure upon her ability to perform her duties and secure compliance with her instructions with a minimum of friction. Reporting Communicable Diseases CommunicaLle diseases can be effectively controlled only if local health authorities have immediate knowledge of the existence and location of each case. Physicians are required by the Xew York State Sanitary Code to report immediately to local health officers all cases of communicable diseases, excepting syphilis, gonorrhea and chancroid, attended by them. When no physician is in attendance upon a case, a report is required from the head of a school or household, or the person in charge of a hotel, board- ing or lodging house, in which the case may be. Visiting or public health nurses, persons in charge of labor or other camps, and of vessels, are required to report under certain conditions. It is particularly essential that public health nurses in New York State be familiar with the requirements of the State Sanitary Code relative to the reporting of communicable diseases. For this reason there is presented below a list of these communicable dis- eases together with a table, prepared for the department's manual, " The Prevention and Control of Communicable Diseases," show- ing by whom, to whom, and under what conditions, reports are required. Ts^urses employed in municipal work should bear in mind the fact that local health boards have authority, under the Public Health Law, to make further regulations not inconsistent with the provisions of the Sanitary Code, and should be familiar with existing regulations in their own municipalities. Diseases declared to be communicable by regulation 1, chap- ter TT, of the Sanitai-y Code: A. Aiitlu-ax Chickenpox Cholera, Asiatic Diphtheria (membranous croup) Dvsentei-y, amoebic and bacillarv 96 State Department of Health Epidemic cerebrospinal meningitis Epidemic oi^ streptococcus (septic) sore throat Epidemic influenza German measles Glanders Mumps Para-typhoid fever Plague Pneumonia a. acute lobar b. bronchial or lobular Poliomyelitis, acute anterior (infantile paralysis) Puerperal septicaemia Rabies Scarlet fever Smallpox Tetanus Trachoma Tuberculosis Typhoid fever Typhus fever Whooping cough B. Syphilis Gonorrhoea Chancroid Ophthalmia neonatorum (suppurative conjunctivitis of the newborn) Public Health JSTursing 97 Reports Kequiked Persons of whom reports are required When? What? To whom? By what law or regulation? Within twenty-four Persons affected with com- municable disease other Health officer Code, chapter II, reg 2 * . cases are seen. than gonorrhea, syphilis and chancroid. Physicians Immediately Cases of cholera, diphtheria, dysentery, epidemic menin- gitis, septic sore throat, typhoid and paratyphoid, scarlet fever, poliomyelitis, or smallpox on dairy farm. Health officer Regulation 8 Heads of hospitals, Immediately upon Cases of communicable dis- Health officer Regulation 3 dispensaries and development of eases in persons under other institutions. disease or admis- their charge. Medical inspectors Immediately Cases of (certain) communi- Health officer Educ. Law, article of schools. cable diseases in school cliildren. XX-A, section 575 Persons in charge of Immediately Children who appear to be Health officer Regulation 4. affected with disease pre- pals, etc.). sumably communicable. School teachers .... Immediately Children in their charge who appear to be affected with diseases presumably com- municable. Principal or person in charge of school. Regulation 4. Attendance (truant) Immediately Children apparently affected Principal or person Special regulation, with communicable dis- in charge of state departments school. of education and tion of liealth officer. health. Heads of households, Immediately Persons in sueh places who appear to be affected with Health officer Regulatioa 5. proprietors or keepers of hotels, disease presumably com- boarding or lodg- municable. ing houses. Owners or persons in Immediately when Any person affected with a disease presumably com- Health officer Regulation 9. no physician is in farms. attendance. municable employed or re- Nurses and persons Immetfiately Any person affected with Health officer Regulation 6. disease presumably com- municable who, by reason of danger to others, seems to require attention of pub- lic health authorities. Persons in charge of Immediately Persons on vessel affected To health officer of Regulation 7. vessel lying with- with disease presumably such municipality in jurisdiction of communicable. as commissioner of State. health may desig- nate. Immediately Deaths from communicable diseases. Health officer Public Health Law, ch. 559, see. 320, San. Code, regu- lation 43-b, chap. Public Health Law, Health ofucers Immediately Cases of communicable dis- State department of ease reported as above. health. art. HI, sec. 25. Health officers Immediately Cases of certain communi- cable diseases on dairy farms. State department of health by tele- phone or tele- graph. Regulation 8. ' Regulations referred to are in chapter II of the Sanitary Code unless otherwise specified. 4 98 State Depart^iext of Health Eegiilation ^i, chapter II of the Sanitaiy Code, which refers to the reporting of cases of certain diseases occurring upon dairy farms, is especially important because of the danger of transmis- sion of the infective agents of these diseases to large numbers of persons through the infection of milk. Each year, as education progresses and the legal requirements are more strictly enforced, the proportion of unre])orted cases grows less. However, a study of returns made to the State Department of Health shows clearly that a large number of cases especially of the so-called " minor " communicable diseases — such as measles, German measles, chickenpox and whooping cough — are still not reported. Failure to comply with the requirements of the law are variously accounted for; most frequently by careless- ness on the part of physicians and failure to arrive at a diagnosis or ignorance on the part of heads of households of the require- ment in regard to reporting when no physician is in attendance. It is a duty of a local health officer to see that every person in his community upon whom the law places a responsibility is given reasonable opportunity to become familiar with the law and then to prosecute persistent or wilful violators when adequate legal evidence is at hand. Inability to arrive at a diagnosis may occasionally constitute a reasonable excuse for failure on the part of a physician to rejDort a case of communicable disease. This excuse will appear less frequently w'lien it is generally understood that in at least numy instances the plea of inability to make a diagnosis of a eom- nmnicable disease reflects upon the initiative and skill of the physician. The Sanitary Code requires physicians to make cul- tures and submit them for examination in all cases in which there is reason to suspect the existence of diphtheria, and to submit blood specimens for the Wassermann test in cases suspected of hav- ing syphilis and for agglutination tests Avhenever there is reason to suspect the existence of typhoid or paratyphoid fever. Unless a physician has resorted to these or other appropriate and readily available laboratory aids, failure to arrive at a diagnosis within a reasonable length of time should not be regarded as an acceptable excuse. Public Health ^N'tjrsing 99 While it is the duty of a public health nurse to bring to the atten- tion of the local health officer any case in which she suspects the existence of a communicable disease, it is also a fact that busy health officers are at times unnecessarily annoyed by being called upon to visit cases when such suspicions are not well founded, This is particularly true in rural conununities in which health officers are busy practitioners and where a visit to a suspected case may involve traveling a considerable distance. Unless the nurse is skilled in the detection of communicable disease or is acting under local instnictions, she should endeavor to have her suspicions promptly confirmed by a physician — whether by the family, school, or other physician depending upon circumstances. Pending the result of his investigation, she should keep' the case under observation and endeavor to see that) necessai-y precautions are taken. Information Regarding Communicable Diseases It is impossible, in a work of this kind, to enter into a detailed discussion of all the common and important communicable diseases. The Division of Communicable Diseases has prepared for distribution a series of circulars containing essential informa- tion regarding the various common communicable diseases. It has also prepared for the use of health officers a manual, "The Prevention and Control of Communicable Diseases," in which are outlined the essential points in the epidemiology of the various diseases. A pamphlet entitled "Cooperation in the Control of Communicable Diseases among School Children" deals par- ticularly with the prevention and control of school outbreaks, and contains the special rules and regulations of the State Depart- ments of Health and Education for exclusion from school of children suffering from communicable diseases or in whose homes cases occur. Two circulars, " The Conduct of an Isolation Period for Communicable Disease in a Home " and " Regulations and Instructions for Cleansing and Disinfection," give detailed advice regarding procedure and precautions in caring for cases in the home. The " Public Health Manual " contains the State Sanitary Code together with important sections of the Public 100 State Departmei^tt of Health Health, Education, Penal and other laws, portions of which relate to the control of communicable diseases. One who has carefully studied these various publications will have acquired a fairly adequate working knowledge of the pre- vention and control of communicable diseases. All of them will be sent to any public health nurse upon request. It is suggested that they be secured and maintained as a "working library," to be used in conjunction with this manual. Upon request, the name of a public health nurse will be placed upon the mailing list for Health News and The Public Health Nukses" BuLLETrisr which axe published monthly and iar the various bulletins issued by the Department. These con- tain articles covering current information in regard to com- municable diseases, as well as other material of interest to health workers. The bulletins constitute an official medium of com- munication with health officers and nurses through which they are apprised of amendments or additions to the Sanitary Code or laws relating to health administration. These can be conveniently bound by use of " ring binders " which can be purchased at any stationery store at small cost. Syphilis and Gonoeehe.! Syphilis and gonorrhea should be considered among diseases common to adult life. Since their etiology has been established it has become possible to estimate their prevalence in a comnmnity by a careful study of its social life. Certain social conditions have been proven to definitely increase their prevalence and during the recent war advantage was taken of this knowledge to produce con- ditions that would tend to prevent their spread. The results attained were veiy promising and justified a continuation of the campaign on a wider scale. The program adopted to produce these favorable conditions is three fold : First, a vigorous educa- tional campaign is necessary; for all classes of society are alike ignorant of the true nature of these diseases, their communi- cability or the possibility of their cure; second, facilities for diagnosing and treating the diseases must be made available. Owing to a reluctance on the part of the public in the past to acknowledge or speak of diseases of the generative organs and the Public Health Xuiii:.i;N"(^^ : ]€,]• cooperation of the physicians in this evasion, their intelligent and successful treatment was possible at only a very few dispensaries and specialists' offices; third, social conditions must be developed that will eliminate the foci of infection and limit the activities of the carriers. The principal agents upon whom the burden of this new pro- gram rests are the public health officials, and of these the public health nurse has unusual opportunities. Her duties will not only bring her in touch with all those who come to the dispensaries but in her follow-up work she will come in contact with other members of the family and community, and this may prove to be her largest field. It is highly important, therefore, that she be adequately quali- fied to do social work. Patients coming to the venereal disease clinic are usually not very ill, frequently they are not uncom- fortably incapacitated and therefore they do not hesitate to dis- continue treatment if the least inconvenience is encountered, unless they have been carefully impressed with the seriousness of their condition. Proper advice and instruction should be given the patient by the physician on the occasion of the first visit, but in many cases it will be necessary for the nurse to continue this education in order to keep the patient under treatment. It is not an unusual experience for a nurse to have several mem- bers of a family, in some instances both parents and children, visit the clinic for examination after one of her visits to the home of a patient. Some patients, by changing their residence, lose contact with the clinic unless the nurse keeps in touch with them. Three classes of persons with whom the nurse will work are the uncured, the untreated and the undiagnosed. Her first work is with the uncured patient who starts treatment at the dispensary. Her specific qualifications in such cases are tact and sympathy. These patients are usually unduly self-conscious of their condition and often feel that they are despised because of their infection. If they are convinced that a cure is possible and that th.ose con- nected with the dispensary are seriously interested in treating them, their enthusiastic cooperation is the rule. While working among the uncured patients the nurse will find persons who need treatment but are not receiving it. Among 'X'0*2 , &TAT3 .Department of Health these will be foimd some who started treatment with a private physician and stopped before they were cured, some who are ignorant of the necessity for treatment or do not know where to go to be treated, and some wdio realize that they are ill but do not recog-nize the disease. All of these should receive the nurse's immediate attention. If those persons who are aware of the nature of their infection are told of the clinic and encouraged to visit it, they usually do so, but those who are ignorant of the true cause of their illness are frequently less tractable. It may be that these patients have made their own diagnoses, or it may be that a physician was consulted years ago and the patient assumes that the present trouble is a continuation of the previous sickness. Such cases should be persuaded to visit their family physician, if they have one, or to go to the dispensary where the proper specimens can be taken. The nurse should qualify herself so as to be able to take specimens from women where gonorrhea is sus- pected. Sometimes it is more desirable to have the first laboratory specimens for the diagnosis of gonorrhea taken from women or children in their homes and not to have them visit the clinic until treatment is begun. Finally there are those persons but recently infected in whom the disease has not been diagnosed. There are two groups of these w^hich w^e should consider. First, those cases that have nor, been discovered, and where the patients may or may not know they are ill. It may be a primary sore that attracts the attention of the nurse or a secondaiy rash and indisposition may cause the patient to speak of himself. There are many signs and symptoms that should arouse the nurse's suspicion, but it must be remem- bered that the diagnosis should always be made by a physiciim and that he should always confirm his clinical diagnosis by having a laboratoiy examination of the proper s]>ecimens. The nurse should, however, invariably report all such suspicious cases with her reason for so doing either to the family physician or to the physician at the clinic and be advised by his judgment with regard to further action. The second group includes those per- sons, who have been unconsciously exposed to either of the diseases. It is among this group that the nurse will be called upon to do her most tactful educating. If a father has just recently Public Health jS^uusing 103 contracted gonorrhea or has a recurrence of his earlier infection, the greatest care must be taken to keep the infection from spread- ing to other members of the family. A member of a family who has contracted syphilis and who has taken precautions while the primary sore existed may not realize the sore mouth he now has is another stage of the same disease. One can readily see how entire families may be infected iimocently from one of their numlier having undiagnosed mucous patches in the mouth. These conditioais must be borne in mind by the nurse when she visits the jiome of a patient who is attending a clinic. Another contact that is urgently in need of the advice of the nurse is the pregnant mother. The nurse should see that she is examined very carefully by a physician, for if infected and treatment is instituted early enough, a well infant may be born. When we consider the great number of stillbirths and deaths of infants under one year of age due to syphilis alone, we can under- stand the importance of this investigation. Persons with either acute or discharging lesions of gonorrhea or syphilis must not be permitted to care for children if it can be avoided. If there is no alternative then they must be most carefully instructed in how to avoid infecting their charges. The public health nurse should cooperate with other specializing nurses of her district. If there is a regularly appointed venereal disease nurse she should be informed by the public health nurse of her investigations and discoveries. If there is no venereal disease nurse in the district, then the public health nurse should learn from these specializing nurses who work in her district the discoveries which they malvc and the suspicions they have of the presence of either syphilis or gonorrhea and should assist in investigating them. Instances are recorded where destnictive pharyngitis or suppurating glands were treated for years as tuberculosis, until a more careful search of the contact condi- tions proved them to be of syphilitic origin. This in a brief way outlines some of the opportunities of a public health nurse in the therapeutic control of venereal diseases ; but she has another large field in the social welfare of the com- munity. Every community has a number of social agencies that are interested in the control of communicable diseases. Many of these 104 State Depaktment of Health are anxious to assist in preventing the spread of venereal diseases but they are not working at maximum eflSeiency because they are not cooperating in a common program. Usually these committees as for example tuberculosis and child welfare committees, Kave been organized for some special work and as that progresses tJiey have gi'adually taken up other activities or would Avillingly assist in other communitj^ service if they were properly directed. The nurse should devise a plan to bring together social agencies and the law enforcement authorities. The cooperation of police magistrates, probation officers and those in charge of wayward girls should be secured in carrying out a general scheme instead of impersonally administering the law. Civilian committees should be stimulated to provide machinery which will tend to restore these unfortunates to that station of society from which they came before they fell into the hands of the law. This is a very large field and one in which much work remains to be done. ISlo person is so well equipped as the nnrse to restore confidence, both in the patient herself and in those who should be interested in her. She can at the proper time report the freedom of the patient from infection and assist in selecting her emplo}Tnent. This interest shown by the nurse will be most helpful in restoring self-respect to the patient. The defective girl will be discovered by her and proper care secured so as to prevent her continuing the life from which she was rescued ; if institu- tional care is indicated it should be secured. If the nurse can demonstrate to a community its share in the responsibility for the care of such patients ^e will have accomplished much for the future health of the people. Relief committees and organizations such as settlements and the Salvation Army posts should be interested in securing treatment for the infected which they encounter. They are always very glad to cooperate with the nurse but they must be interviewed and a definite plan outlined. Local commercial and industrial associa- tions must be interested. It will be found that many of these organizations have already started work according to their own plans and it will only be necessary to coordinate this with the community work. A fourth activity is to provide adequate recreational opportuni- ties for the young people and to secure proper supervision over Public Health Nursing 105 those which are already functioning. This is a most important piece of work aiul great care must be exercised in choosing the committee wliich will have it in hand. They must be possessed of sound judgment and must be appreciative of the demands of the young people. Experience has sho\\'n that a suffi- cient variety of well organized places of amusements where the young people can feel free to do what they wish, provided there is order and decency, will do more toward controlling the spread of venereal infection than many laws. The public health nurse may find when she starts work that, unless she has been specially trained, the social service phase of her activities will be exceedingly difficult. Even if she has been trained in social service methods in one of the larger cities, these will have to be gTeatly modified to be of value in the rural dis- tricts. This must not discourage her. She must make the start, relying on her tact and common sense to guide her. One great temptation which she must early learn to avoid is the devotion of too much time to the individual case. Her work is commun- ity work and preventive in character rather than therapeutic. Therefore when she seesi an infected person her first reaction should be to protect the well and to limit the contacts. She will be called upon to give advice more often in venereal disease work than in any other but she must remember to speak advisedly and always to refer these people to the physician for diagnosis and specific advice. Her position as an educator is an important one and she should always try to find time to " talk it out " with a mother or girl who is puzzled over some sex problem. Mothers will want her to help them to instruct their children and the nurse should be prepared to offer helpful suggestions; especially should she teach the mother the correct names of the generative organs. Much of the reluctance of the average person to talk of sex matters, is removed when his or her vocabulary is enlarged to contain these correct terms. In a word, the public health nurse's work will be medical, social and educational. Some clients will require all three, others but one or two, and the nurse will be obliged to determine which they need from her observation at the time of the visit. Which- ever is indicated should be given, for all are equally important and valuable to the community. 106 State Department of Health CHAPTER VIII Public Health Nursing and Tuberculosis Tuberculosis, a communicable disease, is preventable and cur- able. Because of its great frequency, wide distribution and the vast amount of suffering whicb it causes, it is the most important disease with which public health workers are concerned. The many and complex underlying sanitary, economic, social and industrial factors responsible for its prevalence, make its practi- cal control exceedingly difficult. There are numerous and varied agencies concerned directly or indirectly in the fight against tuberculosis. Of these the tuber- culosis hospital is undoubtedly the most important single agency; the tuberculosis visiting nurse ranks next. In this chapter are described the duties of and procedures to be followed by nurses engaged in tuberculosis work. For details regarding the nature of the disease, its causes, sjanptoms and treatment, the reader is referred to the pamphlet entitled, " What You Should Know About Tuberculosis." Tuberculosis may attack any individual, regardless of age, sex, race, or social status. It is, however, becoming a class disease, i. e., "a disease of the masses." In this country it kills annually between 150,000 and 160,000 (about 9 per cent of all deaths), and of this number the pulmonary form causes over SO per cent. About one-half of these deaths occur in individuals between 20 and 40 years of age. It has been estimated that out of the present population of 100,000,000 in this countiy about 9,000,- 000 will succumb to this disease unless the proper measures are carried out. From the results obtained at Framingham, Mass., it would appear that for every death from tuberculosis, there are at a given time about eight active cases of the disease, of which between six and seven are pulmonary tuberculosis. Tubei'culosis of the lungs is the type of the disease with which the public health nurse will be most concerned ; therefore what follows relates mainly to pulmonary tuberculosis. The following classification is the one ordinarily used to desig- nate the severnl stages of the disease: Public Health jSTuksing 107 Incipient (beginning) : There is very slight affection of one or both lungs. There are no severe symptoms, such as high fever, rapid pulse, dyspnea, great weakness, large hem- orrhages, or severe cough and much expectoration. Tubercle bacilli may be present or absent. 'No other part of the body is tuberculous and there is no other illness. Under proper treat- ment 3 out of 4 patients in this "early" or "curable" stage apparently recover. Moderately advanced: There is a larger area of involvement, but not much lung tissue has been destroyed and while the patient has, as a rule, more marked symptoms of the disease he has no serious complications and is not usually physically inca- pacitated. About 1 out of 5 moderately advanced patients appar- ently recover under proper treatment. Far advanced: The patient has a large area of lung affected, and his lung tissue is being destroyed. His symptoms are marked and severe; he often has serious complications and is practically incapacitated. Only 1 out of about 150 to 200 patients in this stage apparently recover. After treatment, one of the following conditions will be found : Unimproved: Condition is the same as when treatment was begun or else the disease has advanced, when it is called a pro- gressive case. Improved: The patient's symptoms have improved, but he may still cough and expectorate tubercle bacilli. Quiescent: The disease in the lungs is stationary or improving and while the patient may or may not cough and expectorate tubercle bacilli his other symptoms are practically absent and this condition has continued for at least two months. Apparently arrested: The diseased lung tissue has become healed and all general symptoms and expectoration of bacilli have been absent for three months. When this condition persists for six months, the case is considered arrested. When an " arrested" case remains so for two years under ordinary conditions of life it is apparently cured. As long as the patient is discharging tubercle bacilli he is an infectious, and an open case. When this giving off of germs has not yet begun or else has ceased, the case is noninfectious or closed. It is obvious that only the open cases 108 State Department of Health will transmit the disease to others when proper precautions are not taken. In very many of the really incipient cases tubercle bacilli are not found in the sputum as ordinarily examined; occasionally a far advanced patient may not expectorate bacilli. However, a noninfectious patient may at any time become infec- tious, which fact is of the utmost importance in connection with the prevention of the spread of the disease to others. Measures foe, Prevention' and Control The measures to be taken to control tuberculosis, to prevent its spread, and to lessen its incidence with the hope of ultimately eradicating it, must be aimed first at preventing infection. When this has occurred active disease should not be allowed to develop ; if it does the patient should be cared for in such manner that not only will he be prevented from transmitting it to others but will himself if possible become arrested or apparently cured. Finally, after arrest has taken place, recurrence or reinfection must be guarded against. Practically, these aims require an enoi-mous nimiber of agencies all working at maximum efficiency and ia harmonious coopera- tion. The necessary measures have been determined and when- ever and wherever they have been properly carried out excellent results have followed.* To prevent infection necessitates that the tubercle bacillus be located and destroyed at its source. Since this is not always pos- sible, every individual should be taught to take the proper pre- cautions in coughing, sneezing, spitting, or otherwise contammat- ing persons or objects with his discharges. Every case of tuberculosis should be located at the earliest pos- sible moment; it is essential that early diagnosis be secured. For this purpose all physicians should be educated in present day methods, and clinics and dispensaries where specially qualified men can be consulted should be available. All persons suspected of having tuberculosis should be repeatedly examined until a definite diagnosis is made. This applies also to those who have * Their employment bonefitg not only the tuberculosis situation but also, directly or indirectly, assists in the solution of many other public health and welfare problems. Public Health Nursing 109 come into more or less intimate and prolonged contact with tuber- culous patients in tlie home, factory, mill, school, etc. As an aid in diagnosis, free labara;tory examinations of sputum and other suspected discharges should he made by local ox state laboratories- It should be emphasized that, whenever possible, a diagnosis should be made without waiting for a positive laboratory finding. All cases of tuberculosis must be reported by physicians to the health authorities, who must record them and maintain con- stant direct or indirect supervision over them until they are appar- ently cured or have died. In the event of a patient leaving the jurisdiction of one health officer to go into that of another, this fact must be reported to the latter so that he may begin super- vision at once. All reports of suspected cases made in writing by any respon- sible individual (which reporting is authorized and should be encouraged) must be investigated by the local health officer; he is required to make every effort to determine whether or not the case is tuberculosis. In the meanwhile the precautions required of positive tuberculosis cases should be applied to suspects. Isolation or segregation of all patients with tubercle bacilli in their sputum, and especially the advanced and helpless case, is obviouslj essential. Such isolation is best secured at a tuber- culosis sanatoxium or hospital ; if this is iM)t practicable isolation should be required at home. In the latter case, the following procedures and precautions, prescribed by the Kew York State Commissioner of Health, must be carried out under the super- vision of the attending physician, health officer or nurse : PROCEDURES AND PRECAUTIONS TO BE TAKEN ON THE PREMISES OCCUPIED BY A PATIENT HAVING TUBERCULOSIS Care of sputum The patient sliould spit into a paper sputiim cup; burn this cup and its contents daily or oftener; hold a handkerchief or cloth before the mouth Avhen coughinp: or s^neezing; use paper napkins or gauze handkerchiefs, which can be burned daily; should not swallow sputum; avoid soiling hands -with sputum — (if this occurs the hands should be thoroughly cleaned with hot water and soap) ; thoroughly wash with hot water and soap any article aecidently soiled with sputimT, shooild not kiBs anyone (it is eBpecially dangerous for the patient to kiss children) ; should not handle raw food imless the hands have been thoroughly washed with hot water and soap. 110 State Depaetment of Health Care of premises, eating utensils and linen Dry sweeping and dusting should be avoided; dust from any source should be prevented, if possible; patient should, if possible, be provided with a separate bed and room, preferably a room which admits much air and light, especially sunlight; patient should have separate dishes, linen and handker- chiefs and other articles for personal use, and these should be washed and cleaned separately. Other precautions Patient should not associate freely with children and should with very special care observe all precautions in their presence; all members of the patient's family and other household associates should be carefully examined for tuberculosis. All apartments or premises vacated by the death or removal of a tuberculous patient must be cleansed, renovated or disinfected as the case may require. A tuberculous individual should not prepare or in any way handle food intended for others which will not be cleansed or cooked before consumption ; he should therefore not engage in such occupation as cook, baker, butcher, milk dealer, etc. Dusty trades, because of the irritant effects of the dust, should be avoided. To prevent infection from tuberculous cows, milk and its fresh products should not be used unless pasteurized except in cases where the cows have been tuberculin tested and shown to be free from tuberculosis. In order that the individual may himself prevent taking in the germs of tuberculosis he should avoid prolonged and intimate asso- ciation with persons known to have tubercle bacilli in their sputum, especially if the latter do not strictly carry out the pre- cautions prescribed. Sleeping in the same bed, or working in the same room with a tubei^culosis patient, if such workroom is small and not well aired and sunned, is especially dangerous. He should not use common drinking cups, or should he put fingers or other objects which do not belong there into the mouth. He should never handle food with unwashed hands. Dusty atmos- pheres and dark, damp, ill ventilated rooms, whether in the home or elsewhere, should be avoided by him. Decayed teeth should receive proper attention as well as any defects of the nose or chest interfering with proper breathing. Children require special pro- tection because they are more apt to become infected than adults. If infection has occurred and, unfortunately this is probably the case in a large part of our present population, it is essential Public Health Nursing 111 that the individual resistance both general and local be main- tained at as high a level as possiljle. The public as a whole should see to it that conditions in the home, factory, mill, school, etc., be so improved that there is no overcrowding, and that there is sup- plied to everyone an abundance of fresh air and sunshine. Eco- nomic and social defects should be corrected as far as possible. Better wages and lower cost of living tend to reduce poverty and want and sufficient holidays and vacations, parks, play- grounds, allow for the necessary amount of recreation. The individual should avoid intemperance or excess in work or play and dissipation of any kind. The diet should be generous and include fat food which tends to increase the resistance against infection ; rest, fresh air and sunshine are essential, as is also the avoidance of the diseases and conditions mentioned above as predisposing to the development of the disease. Children from tuberculous families, those who are anemic and the so-called pre- tubereulous, should be cared for in preventoria or in " open air " schools, where the physical care of the child takes precedence over its education. Preventorium treatment for " run down " adults is also most desirable. When the disease has developed, every effort should be made to obtain its arrest. For this purpose treatment at a sanatorium or hospital is by far the most desirable ; that at a camp or at home under the supervision of a dispensary or class ranks in value in the order given. When the disease has been arrested every effort should be made to avoid a recurrence or a reinfection. The general public, including the tuberculous individual, re- quires enlightenment as to the tuberculosis problem so that the necessary statutes may be enacted and properly enforced, and institutions and other agencies, public and private, established and maintained. The public should be made to understand thoroughly that the tuberculous patient should not be shunned, but so aided that he will not only not be a menace to the community but also be restored to useful citizenship. 112 State Department of Health The Tuberculosis Xue^e In 'New York State, nurses engaged in tuberculosis work are employed in one of several ways. In counties where the estab- lishment of a tuberculosis hospital is mandatory, the board of managers of such hospital is required and in other counties the board of supervisors is authorized to " employ a county nurse, or an additional nurse or nurses, if it deems necessary, for the dis- covery of tuberculosis cases and for the visitation of such cases and of patients, discharged from the hospital and for such other duties as may seem appropriate." Under the authority of the public health law, the board of health of any municipality may appoint such nurse or nurses. Local tuberculosis organizations, county or city, employ visiting nurses either alone or in conjunction with some public agency. Depending upon how these nurses are employed, their fields of activity will necessarily vary as will the scope of their duties, though to a minor extent. For instance, a nurse employed by the local health authorities acts as the repre- sentative of the health officer and as such has certain official duties and responsibilities which the private nurse does not have. Or a nurse attached to a dispensary acts as the physician's assistant, taking temperature, pulse, respiration and weight, recording same, preparing patients for examination and amplifying the physician's instructions. In the main, however, their activities are practically identical; what follows is generally applicable. Depending upon the size of the locality, and the amount of tuberculosis work already done, the nurse may have such functions to perform as will arouse sentiment in the community for devel- opment of tuberculosis work or more active prosecution of that already begun. It is advisable for the nurse on entering her field to make a survey or study of all conditions and factors relating to tuberculosis in the community. This should include a tabulation of the actual number of reported cases and deaths, and the numeri- cal ratio Ijotween these and information regarding all institutional and other facilities. I'ho attitude of the physicians and cooperat- ing public health agencies, any systematic work already under- taken or proposed, the enforcement by local health officers of the Public Health ISTuiisiNa 113 tuberculosis law and any other conditions wliich may aifect the local situation should be known to her. Such a survey will serve as a basis for the planning and carrying out of her duties. She may encounter either inertia or actual opposition, due to igno- rance or prejudice on the part of individual patients and their families or of other members of the community. Kegard for racial, religious and local customs is necessaiy ; in order to accom- plish results — and really large and important results cau and should be obtained — it is essential that she exercise good judg- ment, tact, patience and kindness in addition to her knowledge and skill. DiscovEEY or Cases* The nurse should obtain from the health officer a list of all reported cases of tuberculosis ; such report is required of all physi- cians, and the local health officer is obliged to keep a con- fidential register of cases. Since these records are open to inspection only by the health authorities of the State and the city, town or village concerned, except by special authorization of the State Commissioner of Health, the nurse, if not employed by or operating under the local health authorities, should request such authorization from the State Department of Health through a responsible officer of the organization employing her. The nurse must not publish or divulge for publication oc communicate to any other person the identity of the persons to whom such reports or registers relate. From the local registrar of vital statistics a 3-5 year list of deaths from tuberculosis should be obtained, f The ratio between the number of reported cases and of deaths should be studied. If it is found that the number of deaths equals or exceeds the number of reported cases it can be properly assumed that there are a large number of luireported and concealed cases, in view of the fact that we estimate that at a given time there are * Since going to press more effective and desirable methods of discovering cases by means of surveys with clinics have been instituted. A special pamphlet on the subject will be prepared and issued. 7 On application the State Department of Health will furnish to all duly authorized nurses lists of cases and deaths, spot maps and other necessary and useful data and information regarding the local situation. 114 State Department of Health 8 active cases to every death. This assumption is also proper if this number is smaller than would be expected from the size and character of the community. School teachers, settlement workers, clergymen, attendance offi- cers, juvenile court officers, employers of labor, etc., often can and should advise the nurse of cases known to or suspected by them. In some instances a house to house canvass may be necessary ; but this should be undertaken guardedly and only with the knowledge of the health officer and the consent of the physicians in attend- aace upon suspected cases. The next step is to visit all reported cases, ascertain their general status, discover whether they have been admitted to or returned from a hospital or sanatorium, or have moved, changed physicians, evaded oversight or died, and bring the living under supervision if necessary. Before making such visits the nurse should obtain the cooj)eration of the health officer and of the physicians; she should call upon the latter and obtain from them the necessary data concerning their " private " tuberculosis cases or, if necessaiy, arrange to visit such patients for this purpose. She should discuss with the physician the need for and desirability of her visitation of patients not reporting frequently to the physicians and of families, in which there has been a death from tuberculosis, in order to obtain data as to the physical condition of the remainder of the family. She should offer to visit positive or suspected cases or former tuberculosis patients to ascertain their present status and to urge thoir reexamination. It is essential that the nurse avoid any actions which may meet with the disapproval of the physician whose consent and cooperation should be obtained in advance. It is inadvisable to visit a home immediately after the death or burial of a patient; a wait of one week at least is desirable. Where tlie necessaiy data may Ix^ o.btaiiu^d from the health officer, attending physician, other visiting nurses, county welfare agent, social service agent, etc., a honse visit will bo unnecessary. Where the family is being called on by another nurse the data should be obtained from her if possible; otherwise the latter should introduce the nurse making the survey. Eveiy Public Health ]!!^ursino 115 endeavor should be made to have all suspected cases examined to determine whether they have tuberculosis. This should likewise be done with all " contacts/' including all members of the household, or of the factory, mill, or shop who have been exposed by living or working with the known case or cases. The individual in question should first be referred to his usual attending or family physician. If he can not afford to pay the physician for his services the latter should be informed of this fact ; very often he will make an examination without charge. If this is not possible, the case should be referred for examination to the dispensary, if there is one, or to the county tuberculosis hospital superintendent.* In counties where no tuberculosis hospital exists the case should be referred to any competent examiner. Under the provision of regulation 42-a of chapter II, Sanitary Code, the local health ofiicer is required, if the alleged case has not been previously reported to him as having tuber- culosis, to take proper measures to determine whether there is reason to believe such person is affected with pulmonary tuber- culosis. Suspects who refuse to consult a physician and to observe the necessary precautions should be complained of in writing to the local health officer. Suspected cases and those who have been exposed should be kept under observation until the medical adviser considers them either positive or no case. If the suspected case has been referred to a dispensary by a lay social worker, the nurse should not assume charge of the case unless the diagnosis is positive and the dispensary itself requests the service of a nurse. If the social worker continues to visit the family, she should attend to the matter of obtaining reexaminations, calling on the public health nurse when necessaiy. If the nurse, however, must visit the family for other purposes she assumes the sanitary over- sight of the patient if no physician is in attendance, and the local health officer has delegated the nurse to act for him in main- taining such oversight. If a physician is in attendance the nurse * Section 47 of the County Law provides that the board of managers of county tuberculosis hospitals shall cause to be examined by the superintendent or one of his medical staff suspected cases of tuberculosis reported to it by the county nurse, or by physicians, teachers, employers, heads of families or others. 116 State Department of Health acts undei his direction. If the nui'se continues her visits she should secui'e the examination and reexamination of the contacts until a definite disposition is made of them. If, however, the patient leaves home or dies, and there is available another worker who is still visiting the family, the latter should assume the follow up work. Examination of Spttium In eveiy instance where an individual has had a cough per- sisting for one month or longer the nurse should endeavor to have an examination of the sputum made. The necessary jars and blanks may be obtained from the local bealth officer or labora- tory and the examination made either at the local or state laborar toiy. Full infoxmation as to obtaining sputum and data for forwarding of specimens (which last should be done through the health officer), is given on the blanks. In this connection it is necessary to emphasize the fact that, while the discovery of tubercle bacilli in the sputum is positive evidence of the existence of the disease, failure to find them does not negative its presence. Repeated examinations, at least three and often more, are neces- saiy before a definite statement as to the patient's not being tuberculous, based on sputum findings, may be made. It should be remembered that when tuberculosis is present a positive diagnosis can and should be made by a competent examiner even though the sputum be negative, since some advanced cases do not expectorate tubercle bacilli. It is of course obvious that while a case with negative sputum may not be dangerous to others, such sputum may at any future time contain the bacilli and the patient thu? becomes a menace. Disposition of Patients When it has been determined that an individual has active tuberculosis his disposition requires prompt attention. In con- sidering this matter it should be borne in mind that the interests of the individual and tbose of his family and of the community at large are best served by having the patient sent to a sanatorium or hospital. For the individual, in the vast majority of cases, this assures the best treatment and therefore the greatest opportunity Public Health Nuesing- 117 for an arrest in early cases, or a prolongation of life in some comfort for those witi. advanced disease. Furthermore, the les- sons learned at the sanatorium by the patient with early disease, even though he does not stay until it is entirely arrested, will be of great assistance to him in completing the " cure " at home. The discharged patient is very often an effective and serviceable health teacher and missionary. From the standpoint of the family, the patient's presence at home would entail avoidable and unnecessary hardships, which are in great part obviated by his admission to an institution. This also removes a source of infection from the family and the community. Efforts should be made to have every case admitted to an institu- tion if possible. Unfortunately existing institutional facilities are not adequate to care for all cases. In IsTew York State, for instance, the provision of one bed for each annual death from the disease is being secured. It is obvious that with such pro- vision (the best now obtainable), all cases can not be accom- modated. However, there are many tuberculous patients who either can not or will not enter an institution because of per- sonal or family opposition, economic and financial difficulties, etc. The following general rules regarding hospitalization of tuberculosis patients are believed to be practicable. If it is not possible to have all cases admitted, all open cases where there are children in the household should be transferred to an institution at once. Home treatment may be substi- tuted when there are no children in the household and when it is possible to obtain facilities at home for the proper out- door treatment under favorable hygienic conditions. If home treatment is to be successful, adequate nursing and medical super- vision over a sufficiently long period, with a patient and family intelligent enough to carry out all details, are essential. Any tuberculous person who either will not or can not so conduct himself as not to be a menace to others should be forcibly removed to a hospital, as provided for in section 326-a of the Public Health Law (see pamphlet, " Compilation of Tuberculosis Laws," fur- nished by the State Department of Health) . Where hospital treat- ment is not available, the patient should be admitted to a camp, if there be one. If he remains at home he should be kept under the observation of a private physician or a dispensary, or a tubercu- 118 State Depaetment of Health losis class. Xo disposition of any patient should be made by the nurse without first securing the advice and consent of either the regular medical attendant, the dispensary physician or the health officer. This is essential as there may exist certain contraindications such as complications which would make high altitude or removal inadvisable. Children suffering with pulmon- ary tuberculosis should be sent to an institution, as also should those who have bone, joint, and gland tuberculosis. Unfor- tunately existing institutional facilities for the care of tuber- culous children are very limited; they should be extended. Those children who, while not actively tuberculous are neverthe- less weak and poorly nourished, whose home conditions are undesirable, and who have been extensively exposed to the dis- ease, should, if possible, receive care in a preventorium camp or open air class. The adult who is " run-down " can also derive a great deal of benefit from preventorium care where such is avail- able. In the case of patients discharged from a sanatorium as arrested, or of those in whom the disease is inactive, the matter of after-care should receive the nurse's attention. These indi- viduals require close medical and nursing supervision in order that the good results which have been obtained may continue. The details as to rest, outdoor treatment, occupation, etc., depend on individual cases and should be prescribed by the physician. It is advisable that the patient be examined once a month; he should be informed as to the possibility of his having to return to an institution on the appearance of evidences of a relapse. Home Supervision Tlie patient who remains at home obviously requires medical and sanitary attention, and in many instances, material relief. The first of these should he given by a private physician or a dispensaiy as the circumstances necessitate and allow. Under the New Yoxk statute sanitary care must be given either by the physician or by the health officer. The phj^sician in reporting a case of tuberculosis is required to signify his will- ingness to perform this duty ; if he will not or can not maintain sanitary supervision this devolves upon the health officer. If the nurse is acting under the latter's direction this duty may be Public Health Cursing 119 delegated to her, in which ease she exercises full sanitary control independently of the attending physician, who may, however, con- tinue to attend the patient. Physicians in attendance upon tuberculous cases often request the services of a public health nurse for the j)urpose of maintaining sanitary supervision. Under these conditions the nurse acts under the direction of the physician in advising and instructing the patient and his family. If the physician is only nominally in charge or unwilling or unable to maintain sanitary supervision, this duty devolves upon the nurse as the representative of the health officer. A health officer has authority to have all repoa-ted cases of tuberculosis in his juris- diction visited by a public health nurse. The public health nurse employed by public authorities can make no distinction between the poor and those able to pay in providing sanitary insti^ction, since this is intended to promote the public health generally. The public health nurse's work includes sanitary instruction and advice as to the patient's well being, subject to the orders of the attending physician, if there be one. Her functions in the home are primarily of a sanitaiy natui'e; nursing, as such, is not to l>e given except insofar as it may be necessary for purposes of instruction, in an emergency, or to gain the con- fidence and good will of the patient and family. Where pro- longed bedside nursing is necessary, a private nurse should be secured, if the patient can afford to pay, and if not a visiting nurse's association should be requested to supply such service. The statute requires that every reported case of tuberculosis be furnished with a circular of information regarding the best method of treatment of tuberculosis and of the precautions neces- sary to prevent its transmission to others. Such circulars are supplied by the local health officer through the physician, if there is one in attendance, or else direct to the patient. "While the circular of information is very useful and, theo- retically, should supply the patient and his family with all the necessary information, practically it is necessary that the nurse give personal instructions and demonstrations. This should include information regarding the nature of the disease and the danger of its spread to others, the method of proper disposal of 120 State Depaetmext of Health sputum or other infectious discharges, both in the home and when abroad, keeping the hands free from infectious material, avoiding the contamination of objects which may be used by others,- the avoidance of unguarded coughing and sneezing and of putting fingers in the mouth, and the prevention of contact infection in the family. The danger of having the patient pre- pare food to be eaten by others should be stressed, as should also the danger of working in the same room, eating at the same table, sleeping in the same bed, or using the same dishes. The official procedures and precautions which are given in a preceding sec- tion must be followed. The nurse should also, under the super- vision of the physician, amplify the latter's instructions as to mode of life and diet, and help arrange for outdoor sleeping facilities, clothing, baths, etc. She should not make any change in the patient^s diet, except upon the physician's advice and con- sent. If there is no physician in attendance and the nurse is tak- ing entire charge of the case, she should appeal to the health officer in matters of a medical nature in which she feels she needs assistance. AVhen giving instruction it is advisable to select some responsible member of the household and teach slowly and care- fully, giving practical demonstrations. It is, of course, necessary that the nurse make certain that her teachings are being followed ; she should make corrections and changes' where and when necessary. In order to allow for the proper carrying out of the essential precautions, the health officer is required to advise the physician as to what he has on hand in the way of sputum cups, paper nap- kins, disinfectants, etc., and to provide the latter with a requisi- tion form, which when properly filled out, must be honored by the health officer and the supplies requested furnished in the amount deemed necessary. Medical emergencies or incidents which may arise in the course of the nurse's visits to the home include the occurrence of hem- on-hagc, pneumothorax, possibly confinement of the patient, or the occurrence of communicable diseases other than tuberculosis in the household. In the case of hemorrhage the nurse should remember that in many instances the bleeding will stop without or in spite of any treatment which may be instituted. If the lioinorvhnge be due to Public Health Nuksing 121 the erosion of a large artery in a cavity or into a bronclius the patient may bleed to death. The nurse should reassure the patient, both by words and actions, acting calmly, quietly and confidently. A physician should be notified, the patient put to bed in a semi-sitting position, with sufiicient support by means of pillows under his back and head to maintain this position, and admonished to remain absolutely quiet and not even talk unless essential. Cracked ice may be given by mouth continuously and cold in the form of an ice bag applied to the chest (heart). The nurse should not leave the patient until the physician arrives. Spontaneous pneumothorax in tuberculous patients is due to the giving way of the pleura and the entrance of air from the lungs into the pleural cavity. If this occurs suddenly, the patient will complain of severe pain in the chest with a sensation of some- thing having given way and will show evidences of shock with a rapid, feeble pulse, hurried and labored breathing, great short- ness of breath, a sense of sufi^ocation, and a clammy skin which may be pale or bluish. The nui"se should call a physician at once. The patient's position varies, it sometimes being impossible for him to Ue down owing to the sense of suffocation experienced. When the condition comes on more gradually the symptoms are not so sudden, severe and pronounced Those cases which recover usually have the pleural cavity infected with pus forming organisms. When a communicahle disease other than tuberculosis occurs in the family, the medical disposition of the case will depend upon the physician in charge, the health ofiicer, or the nurse if she is authorized to act. Wherever possible such patient should be promptly removed to a hospital. The Sanitary Code (Chapter II) makes specific provision for either the isolation or removal of cases of certain communicable diseases. In the case of diphtheria, scarlet fever or typhoid fever occurring in a hotel, lodging or boarding house, the health officer having jurisdiction is required either to have the patient removed to a suitable hospital, if avail- able, or else to isolate the case on the premises if this can be done safely, the other inmates to be removed from the premises if necessary. When required, the municipal authorities must make provision for the medical and nursing care of such cases remaining 122 State Department of Health on the premises mentioned. In those localities where either a pri- vate or public agency employs visiting nurses for the specific pur- pose of attending cases of infectious or communicable diseases, it will usually be advisable for the tuberculosis nurse to with- draw temporarily from the family and permit the communicable disease nurse to take charge of both the tuberculous and other cases. Maternity Cases in Family When the patient or some other member of the family is to be confined, the disposition of the case rests with the physician, and if there is none, with the nurse in charge. It is advisable that the patient be removed to a maternity or other hospital. The tuber- culosis nurse should not be expected to attend the patient during confinement; a physician, midwife, or visiting nurse from a public or private agency should be secured if possible. Dental Service Dental service is essential but may often be difiicult to obtain, either because the dentist refuses to handle infectious cases, or can not or will not give free service to the indigent, or both. In order to overcome the first objection it is advisable to obtain a certificate from the health ofiicer as to the patient's being non- infectious, i. e., not expectorating tubercle bacilli. A dentist willing to give his services free should be found; if this be impossible, efforts should be made to obtain funds from some charitable individual or agency. It may be necessary to send the infectious patient to another locality to obtain the required service. The Family in an Insanitary Hoitse For the family in an insanitary house one of two procedures is possible. The ninso may either attempt to have the conditions corrected, or failing in this she may take steps to bring about the removal of the family to a better home. For the first purpose, she should make complaint in writing directly, if so authorized, or else through her superior, to the department or bureau having jurisdiction. When removal is deemed necessary, if the family is being assisted or maintained by a charitable agency, recom- mendations to and cooperation with the latter should be Public Health Xursing 123 made and given. The consent of the health officer is not required for such removal; it must, however, be reported to him within 24 hours of its occurrence so as to allow for the necessary cleansing, renovation, or disinfection. In case a representative of a charitable agency desires to remove a family which is under the supervision of a nurse, the rules of the agency will govern; but it is best that the charity agent consult with the nurse or health officer, who may be able to advise as to the desirability of the new premises. The reporting of the removal to the health officer is required of the agent who should also inform the nurse so as to save her a trip to the wrong address. Relief As is generally known, tuberculosis is in many cases compli- cated by poverty. This is unfortunate, not only because of its unfavorable influence in connection with the development of active disease, but also in that it may, unless relieved, militate against the patient's receiving proper care and treatment. When the breadwinner of the family is affected, whether he go to the hospital or remain at home, the difficulties are obvious. In any case, the securing of the proper appurtenances, such as cure chairs, blankets, proper clothing, medicines, and food, presents a prol)lem. Assistance rendered without cost either to remedy or alleviate social or physical defects is denomi- nated relief. This may be medical, consisting of free medical, hospital or dispensary care, or material, including shelter, food or clothing. It may be secured through residence in an institution, when it is named indoor relief. Outdoor relief is that provided outside of a hospital. The sources from which assistance may be obtained are either public or private and vary from a single individual to an organization or institution. Which of these are available in a given community usually depends on its size, resources and enlightenment. It is not intended to go into details here regarding the securing and administering of relief. In order to be effective relief must be adequate, i. e., sufficient both in kind and amount. It should also be timely and administered so as to assist the recipient without pauperizing him or making him a helpless dei>endent, which he might other- wise not become. A good knowledge of the principles governing 124: State Department of Health charitable work, combined with good judgment, are essential; the public health nurse may have the latter, but not necessarily the former. For this reason, and also because it is more advan- tageous for all concerned, the nurse should not administer relief if there is any existing agency which can do so. If the latter does not function satisfactorily, the nurse should make efforts to discover the reason rather than to administer relief herself. Evea when private individuals provide relief it may be possible to have them attend to the details of its administration. The nurse should know the charitable organizations in the community and cooperate with them; and while not directing the relief work, she should make recommendations to those who are doing so. In an emergency promptness of action is essential. When a lack of food, fuel or clothes, is found, the central office or nearest agent of an organization should be communicated with immediately. Very often in localities where there is no relief organization, one may be initiated and established as the result of the nurse's request for aid from different private individuals. Social Wokk oe the Nukse When a social worker is not available it becomes necessary for the public health nurse to perform duties of a social character, which may go so far as to involve a complete readjustment of family conditions. Certain forms of social work, e. g., mothers^ meetings, special classes for selected cases and clubs for boys and girls are really legitimate preventive activities. COOPEEATION and DiVISION OF DuTIES BeTWEEN THE SeVEEAL, WOEKEKS IN A TuBEECULOUS FaMILY From what has been said it is evident that there may be one or more of a number of individuals visiting a tuberculous famUy for purposes concerned with the presence of the disease. In order that the interests of the individual and his family and those of the community at large may best be served, it is essential that the scope of duties of each of these be clearly defined. This matter has been previously indicated, what follows is supple- mental. Public Health Nursiitg 125 The provisions of the code of medical ethics, which prescribe a standard of conduct for physicians in their relation with one another and with the public, must be carried out insofar as they are applicable. The nurse visiting a case attended by a physician, is essentially the latter's assistant; if the nurse is employed by the State or a municipality she also usually represents the health officer or other authority under whose direction she acts. Where a district or poor physician attends a case, his relation to the patient is the same as that of a paid private physician, and he is entitled to the same courtesies. Sometimes technical and other considerations modify the situation. For instance, the physician may be required to make only one visit or to attend the patient for a specified time or to attend only such patients as consult him upon the written order of a public author- ity during the period specified by such authority. These details may affect the relations of the nurse or social worker visiting the family to such district physician; if deemed advisable, they may refer such patients to other physicians, or to dispensaries, either with his consent, or when his period of attendance expires. In some communities the system which provides medical attention to the poor does not always operate satisfactorily, and the nurse may be justified in acting upon her own initiative. It is well for the nurse to be informed as to the precedures necessary to secure the services of a charity physician so that in an emergency there may be no misunderstanding or technical evasion by anyone con- cernefl. As an illustration of the differences in procedures, it may be stated that in some localities the physicians may not be required to respond to an emergency call except upon a police order. In other districts it may be necessary for the patient himself or a member of his family to make application in person for medical service. Many poor patients are not actually seen by any medical worker except the nurse, although, nominally at least, there should be a physician in attendance. If there is none, or if he permits the nurse to act for him, then all sanitary and medical problems in the family come definitely within her province. If a responsible charitable agency is interested all economic matters in the family 126 State Department of Health are quite as definitely within its province. When, on the other hand, there is a physician and lay social worker but no nurse attending, the medical direction and disposition of the patient rests entirely with the physician, unless the health officer has cause for interference, in which instance the latter can have the case visited by a nurse ; such procedure is often necessar)^ and is justi- fied if the physician is only nominally in attendance or does not maintain sanitary oversight. Should the necessary cooperation between the social worker and the nurse visiting a tuberculous family become impossible, or should the withdrawal of either become advisable, it is the nurse who should continue to visit the family. She can not discontinue her visits, if she is acting under the direction of a public health authority, without con- sent of such authority. The health officer has the right to cause any reported case of tuberculosis under his jurisdiction to be visited by a public health nurse, under which circumstances the latter acts as the health officer's representative in the enforce- ment of the law, and the continuance of her activities is essential. In those cases where several different agencies employ nurses for field work it is often necessary to exercise care in order to prevent duplication of effort. The public health nurse acting under the direction of local or state health authorities has certain legal duties to perform, as previously indicated; these she can neither delegate to others nor neglect. Where it is necessary for nurses representing other agencies, such as hospitals, dis- pensaries and tuberculosis committees, to visit families in charge of a nurse representing a health authority, the ordinary rules of courtesy should be observed. The nurse primarily in charge of the family should be consulted first; she may be able to accom- plish the work or obtain the information desired, in which case no visitation by others will be necessary. Where it is desirable that the nurse from the private or other agency keep the patient or family under observation or visit them frequently, a plan of cooperation should be agreed upon by all concerned. It may be feasible, for instance, for the nurse representing the health author- ity to make the first visit, provide the first instruction, etc., and Public Health N"uRsriirG 127 make only occasional subsequent visits, while the other agencies concemed are closely in touch with the family's affairs. Har- monious coo]3eration is absolutely essential. Other Forms of Tuberculosis The public health nurse usually visits only pulmonary and laryngeal eases of the disease; other forms, such as bone, menin- geal, kidney and peritoneal tuberculosis, are not usually com- municable and sanitary supervision may not be necessary. It may be sufficient for the nurse to call occasionally on such families to determine that no other members have suspicious sjmiptoms or are affected with the disease. The number of cases of nonpulmonary forms of the disease is so large that it is not practicable for the public health nurse to follow them up or, in many localities, even to make any visitation of them. Such patients should be removed to institutions or be taken care of by a visiting nurse from a private agency or settlement house, or community center. In large cities cases of bone and other surgical tuberculosis may be visited by surgical nurses from private agencies. Eight of Entrance and Inspection Eegulation 15 of chapter II of the Sanitary Code provides that no person shall interfere with or obstruct the entrance to any house or building by any inspector or officer of the state or local health authorities in the discharge of his official duties, nor shall any person interfere with, or obstruct the inspection or examination of any occupant or any such house or building by any inspector, or officer of the state or local health department in the discharge of his official duties. It is, therefore, obvious that the public health nurse, in acting for or under the direction of a local or state health authority, has the right to enter premises and visit occupants when necessary to do so in the performance of her duties. In some communities it has been found practicable for the health officers to delegate their authority to nurses employed by private agencies so as to facilitate their work. Milk and Eggs for Tuberculous Patients When the nurse has milk and eggs available for distribution to her patients she should, in justice to all concerned, pursue a 128 State Depaetment of Health definite policy in her distribution o£ suck food. Milk and eggs axe very apt to be misused unless the nurse exercises care and discrimination. It may be very useful for her to observe the following rules: 1 The patient and family must be unable to buy them. 2 The patient must thoroughly cooperate with the nurse and observe her instructions — and when the patient fails to do so the furnishing of milk and eggs should be discontinued, 3 'No incipient patient should be given milk and eggs unless there is sufficiently good reasons Avhy he can not go to a sanatorium. 4 No patient should be given moj-e than one quart of milk daily and one dozen eggs weekly except for special reasons. 5 Milk and egg-s should never be given as relief or as supple- mentary relief. 6 1^0 distinction should usually be made between classes of patients with regard to their supervision by private physicians, dispensaries, tuberculosis classes and health officers if the super- vising agency approves the patienf s application for milk and eggs; hospital patients, however, should not be eligible. 7 As soon as the patient or family is able to buy milk and eggs the free supply should be stopped and they should be advised of the fact. 8 Application for milk and eggs should be made in writing by the patient or head of the family, and it should be agreed that they will be used only as directed by the physician. 9 Milk and eggs should not be given to any patient who is not under the supervision of a public health nurse who has agreed to assist in the enforcement of these rules. 10 In supplying milk and eggs patients should be given preference as follows: (a) Tuberculous children under 16 years of age; (b) Advanced patients who can not assimilate other food ; (c) Incipient patients; (d) All other tuberculous patients. Organizhstg a Local Tuberculosis Campaign It may be that the nurse will find that little or no antitubercu- losis work hns been done in certain communities and it is then her Public Health Kukspng 120 proper function to stimulate such work. It is usually advisable that different individuals and agencies, such as physicians, health authorities, business men, women's clubs, clergymen and the press be interested, the last two being able to speak on the subject from the pulpit and through the newspapers, respectively. A tuberculosis exhibit should be given and a tuberculosis society formed. A dispensary should be established with a well qualified physician and nurse attached to it; if advisable and feasible, a camp should be started. Though in the beginning it may be necessary to obtain private funds for these purposes, it is usually not difficult to have the municipality later supply the fund and take charge of the activities. Eecoeds Records are of secondary importance ; they are necessary, how- ever, for obvious reasons. They should be simple and at the same time sufficiently complete. The State Department of Health, and the State Charities Aid Association Tuberculosis Committee, in cooperation, have prepared a set of records intended for the use of county tuberculosis nurses, but adaptable with slight modi- fications for other nurses engaged in tuberculosis work. Complete sets of these may be purchased from the latter organization. 5 ir.O Statk Dei'ai;tmi XT oi- TTkai.th CHAPTER IX Cooperation of Health and Educational Authorities in the Con- trol of Communicable Diseases School medical iuspcction lias two definite aims; first, the early recognition and exclusion from school of children suffering from acute communicahle disease, as a prime factor in the control of local epidemics; second, the recognition of physical nnd mental defects and ahnormalities and chronic disease among the pupils, followed hy the institution of remedial measures. CooPEiJATiox IN Scnooi. Medical Inspection Since the enactment of the amended Public Health Law in 1913, and of the amendments to the Education Law relating to the physical welfare of school children in the same year, there has arisen from time to time an apparent conflict of authority. So many questions have come up as to the respective duties of the health officer and the school rhedical inspector that it was thought advisable to define as closely as possible the duties of each office and to point out the methods to be used in following up children absent from school presumably on account of communicable dis- ease. It should be remembered that the Education Law was enacted subsequent to the amendments of the Public Health Law, and by imjjlication amends and takes the place of paragraph 2 of section 21-b of the Public Health Law. This law i)rovides that a school medical inspector shall be appointed for each district to examine all children who have not had health certificates issued after examination by their family physician. Section 575 of the Edu- cation Law " ])rovides that pupils, who upon investigation show * Section 575 of the Ediwatlon Law: " Whenevt-r uixm investigation a pupil in the pul)lic schools shows svniptonis of smallpox, scarlet fever, measles, chickenpox, tuberculosis, diphtheria, influenza, tonsilitis, whooping cough, nuunps, soal)ies or trachonui. he shall be excluded from the school and sent to his home immediately, in a safe and i)roi)er conveyance, and the health officer of the city or town shall be inunedialely notified of the existence of such disease. The n"u'dical inspector shall cxamii\c each pupil returning to a school without a certificate from the health otliccr of the city or town, or the faniilv physician, after absence on account of illness or from iniknown cause. Such medical inspector may niaJ it is their duty to report promptly all the facts to the local health officer. It is not the health officer's duty to visit all cases of sickness unless there are sufficiently good reasons to believe that tlio case m;iy be one of conununicable disease. It will be found of great advantage to the school nurse or attend- ance officer to keep a small notebook to record the name, age and address of any child who may be absent from school on account of communicable disease, and the names of other members of the family attending school. The school medical inspector should also keej) a record of communicable disease diagnosed by him and reported to the local health authorities. On the other hand, the health officer should not only investigate and visit or cause to be visited every household where a case of comnuinicable disease is reported or suspected to be present, but also should make a list of the names of all the persons who live in the house and this list shoidd be kept and the house revisited from time to time in order to ascertain whether or not quarantine is being observed in the infected liousehold or whether any of the contacts have "come down" with the disease. If communicable disease exists in epidemic form in any community, it is generally wiser not to close the school but to keep the various classes under da'iy siipei'vision and to exclude promptly jx-rsons suspected of develoi)ing the diac^ase. It will usually be found preferable to exclude a certain class or classes from school rather than to close Public Health NuRsrA^G 133 the entire school. Whenever an outbreak occurs, it is recom- mended that the school medical inspector make daily visits to the school if daily inspection is not made and inspect all the children, and the health officer will be expected to cooperate with him and render all assistance possible, but it is believed that it is the pri- maiy duty of the school inspector assisted by the school nurse, if one is employed, to perform this service. Before making examinations of children, whether for an ordi- nary physical examination or for the presence of a communicable disease, the usual aseptic precautions should be taken. For examining the throat an ample supply of wooden tongue depres- sors should be provided, also facilities for disinfecting thermo- meters. Physicians and nurses should use extreme care that the hands are thoroughly washed before and after each examination of the nose and throat. At the close of an epidemic terminal fumigation is not always necessary, but the school room or rooms where cases of communi- cable disease have been detected should be scrubbed with soap and hot water and then given a thorough airing. During the exist- ence of an epidemic it is of great advantage to have w^^niings issued in the press and also in the form of bulletins in which refer- ence is made to the fact that the Public Health Law requires heads of families to report to the health officer suspected cases of com- municable disease coming to their notice if no physician is in attendance (Reg. 5, Chapter II Sanitary Code.) The ]^ew York State Education Law provides for the medical inspection of all pupils attending the public schools in the State. It states that medical inspection shall not only include the examination of school children for physical defects but shall also provide for the exclusion from school of all pupils who show symptoms of smallpox, scarlet fever, measles, chickenpox, tuber- culosis, diphtheria, influenza, tonsilitis, whooping cough, mumps, scabies or trachoma. Although the law is quite specific on many points, it does not, in this section, definitely state how these diag- noses shall be made or how pupils shall be excluded from school. It does provide, however, that upon returning to school after 134 State Departmknt of Health al)seiK*e on account of illness from unknown cause, each pupil shall he examined by the medical inspector unless he has a cer- tificate from the health officer of the city or town, or from the family physician, and reji:ulation 20 of chapter II of the Sani- tary Code, already quoted, furthermore requires that if such cer- tificate is signed by the attending physician it should be counter- signed by the health officer or school medical inspector. The communicable diseases mentioned in the law occur more frequently among children of school age than in any other age group, and every effort should he made to prevent the spread of communicable disease among such children. The law further provides that the Commissioner of Education may adopt rules and regulations, not inconsistent with the ]u-o- visions of the section of the law, for the purpose of carrying into lull force and effect the objects of the law. There is no question but that teachers * should he taught the beginning symptoms of communical)le diseases, that children should be excluded from school who have evidence of such dis- eases, and that such children should not be allowed to return to school except on certificate of the physician countersigned by either the school medical inspector or the health officer. Juvenile Health Officers for School I\ooms The appointment of a " Juvenile Health Officer " in each school room — appointments 1o he made by the teacher at inter- vals and a])pointoes to include both boys and girls — will stimulate interest, have an educational infiuence, and may furnish the teacher, nurse, or medical inspector with valuable information. The Juvenile Health Officer should be dejnitized to submit to the teacher any information in regard to chiblren out of school on account of illness who mav be suft'eriuiz; from a communicable * The State Doi.artmont of Education is (lovclopint: a system tlii(iu,i:li wli tills instruct ion will lie ''iven to teachers. PuBi.ic Heai/i'ii XuRsrxc. 135 disease. A coiiveiii(>iit form for such a report, shown bclov;, wil be popuhir with the juvenile official. DIST. NO WEEK ENDING Juvenile Healtji Officer's Report GRADE 19. 3 Number of pupils enrolled Number absent because of illness Number absent because of typhoid fever . diphtheria smallpox chickenpox scarlet fever (scarlatina).. whooping cough mumps measles pinkeye, Other diseases (write names of Other absentees (cause of absence given) Day of Week M T W T F Javena3 Health Officer. In order properly to control outbreaks of communicable dis- eases, and in order to prevent the occurrence of cases of such diseases in the public schools, a series of regulations have been drawn up }\v the State Commissioners of Health and of Education, in accordance with the provisions of the Educational L;nv, definitely defining the duties of tlie school medical inspector, principal, teacher, and local health officer, as follows: Rules and Regulations for Health Officers and School Medical Inspectors for the Control of Communicable Disease 1 Whenever a school teacher, a school medical inspector, school nurse, or attendance officer discovers that any school child absent from school is affected with any disease presumably communicable, he or she shall report forthwith to the local health officer all 136 State DEPAKT:\rENT of Health known facts relating to the illness of the child, together with the name, age, address, school attended tmd gi-ade of such child and the name of the physiciiai, if any, in attendance. 2 When no physician is in attendance, it shall be the duty of the local health officer to investigate the nature of the illness of every person within his jurisdiction reported to him as affected with a disease presumably communicable. 3 Whenever a case of communicable disease occurs in any school, it shall be the duty of the school medical inspector to notify the health officer of such case immediately and to ask his cooperation and assistance in controlling the disease in said school. 4 Whenever a case of communicable disease occurs in any school in his jurisdiction it shall be the duty of the health officer to render every assistance possible to the school medical inspector in the control of said disease. 5 Whenever a case of communicable disease occurs in any school, and there is no school medical inspector directly responsible for the prevention and control of communicable disease in said school, it shall be the duty of the local health officer to take all steps necessary to prevent the spread of the disease. 6 Whenever a child in attendance at school is reported to the school medical inspector ])y the school nurse or teacher as being affected with a disease presumably communicable, it shall be the duty of the school medical inspector to examine the child promptly, and if such child is affected with a communicable disease the school medical inspector shall report immediately to the local health officer all the facts relating to the illness, together with the name and address of such child. 7 Whenever a case of communicable disease in a family with a child or children of school age is reported to the local health officer, it shall be the duty of the local health officer to notify the school medical inspector ])romptly of the name, age, schotd attended, grade and address of sucli cliild ov children and the nature of the coiniinuiicnble disease, and also of the names, ages, schools atleiided ;iiid grades of all oilier children in the same household. Public Health Nursi-xg 137 If these rules and regulations could be fully understood and put in force by the local authorities, a very long step would be taken in the control of communicable diseases in schools. In far too many of our smaller cities and in our villages and towns, there is a desire on the part of the school trustees to close a school whenever there is an outbreak of a communicable disease. The Education Law does not cover this situation and the trustees undoubtedly have the authority to take this action. Here is where tact and cooperation are necessaiy, for the school trustees may in their right do as they choose, but if properly approached, and if the situation is properly presented to them, they will do the wise thing and provide for the proper following up of each absentee from school, and see that the cases are controlled out- side of the schools, and that cases of suspected illness are excluded promptly. ms Statk Depai;t.m Hi CHAPTER X The Public Health Laboratory The public health laborator}^ is an institution the initiation and development of which has occurred within the memor\' of sonic of the readers of this ni;inual, l)Ut it is to-da_v generally i^egarded as a most important and essential feature of public health work. The following diagram, showing the number of diagnostic specimens (in diphtheria, tuberculosis, typhoid, syphi- lis, and other diseases) examined in the New York State Labora- tory aniuially since 1913, indicates gTaphically the extent of increase in demand for this branch of laboratory service. Total Number of Diagnostic Examinations of Diphtheria, Tuber- culosis, Typhoid Fevsr, Syphilis and other Diseases ^ L 8i7. •■^ r^ Public Health NuRsrxo 139 The New York State Laboratory, located at Albany, is in charge of the Director of the Division of Laboratories and Ke- search of the State Department of Health. Generally speaking, its most important functions are the examination of diagnostic speci- mens from cases of communicable disease ; the analysis of samples of water from public water supplies; the preparation and distri- bution of antitoxins, serums, vaccines and chemical preparations used for the prevention and treatment of communicable disease, as well as culture media and outfits for the collection of speci- mens for examination; and research directed toward improve- ment of old and the development of new methods of procedure for the prevention and treatment of disease. Because in many instances prompt reporting upon examination of diagnostic specimens is of great importance and transportation of such specimens necessarily consumes time and involves other difficulties, many counties and other municipalities have estab- lished local laboratories in which such specimens are examined. Bacteriological tests upon milk samples, the nature of which makes transportation for considerable distances impracticable, are usually also made at local laboratories. It is not essential that the public health nurse be intimately aet[uainted with the details of laboratory procedures. She should, however, be familiar with the functions of the laboratory and she should know what specimens will be accepted for examination and under what conditions, and how to prepare them. In most instances when preparing laboratory specimens she will be working under the supervision of a health officer or other physician, who will also assume responsibility for interpreting reports ; but it will often prove a decided advantage if the nurse has sufficient general knowledge to enable her also to interpret Iriboratory reports intelligently. In the following chapter those diseases in which laboratory examinations are of such value that ])hysicians require them constantly are briefly discussed and the purposes of such examinations are explained. 140 State Depaetaient of Health CHAPTER XI Laboratory Service Genekal Considerations Laboratory supplies furnished by the State, including anti- toxins and other products for prevention and treatment, and diph- theria culture tubes and outfits for collecting laboratory speci- mens, are distributed through local supply stations maintained either by health officers or under their supervision. Physicians and nurses secure their supplies from such stations, except where they are issued through local laboratories. Health officers receiving supplies for distribution obligate them- selves to keep them under proper conditions, to exchange those which are perishable as often as necessary, and to make them easily accessible to those having occasion to use them. Packages containing antitoxins and other perishable products for immunization or treatment have noted upon them the dates of preparation or testing. The time after which the product should not be used is recorded either on the label or on the circular en- closed in each package. The packages should be kept constantly in a cold dark place, preferably in an ice chest. If kept under such conditions, they will retain their strength for the periods indicated by the expiration dates. Diphtheria culture tubes con- tain " slants " of grayish white culture medium (coagulated blood serum), wliicli sliould present a smooth, moist surface. Products of expired date or culture tubes containing media which has dried and separated from the sides of the tubes should never be accepted for use. Health officers are supplied with containers for various speci- mens to be transmitted to the laboratory, including material for cultures, specimens of blood, fecal and urinary discharges, sputum, pus, etc. These are so equipped for mailing as to com- ply with postal I'egnlations and should invariably be used in accordance with directions accompanying them. Accoin])ii]iyiiig ea<^li specimen '' ecimens should be allowed to dry pre])aratory to fixing by heat and staining. Laboratory practice, however, requires that this preliminary diagnosis be confirmed by exami- nation of material from a culture. This is especially important when examination of the smear has failed to reveal the ])resence of diphtheria bacilli. If Vincent's angina is suspected a smear should be sulnnitted. It is necessary, however, to use the swab more vigorously and Avith more pressure than in securing material for cultures. When special examinations or tests are required, this should be clearly indicated upon the information l>lanks accompanying the specimens. It is now well known that there is only one effective method of treatment f(tr cas(>s of ]) wounds from which air is excluded. Penetrating wounds anulletins heralding the special event which nobody should miss. Formal lectures, curb-stone and noon-hour talks and other' brief and informal addresses have ]yeen utilized to deliver a s})ecial message to the people. On nearly all of these occasions specially prepai-ed free literature has been ofl'ered to anyone who will take it. This type of work requires careful planning, intelligent oliservation of the reaction of the people and prompt seizure of opportunities resulting from interest aroused. Results are meas- ured not in the amount of literature distributed, the number of talks given, or the size of the listening crowds, but in the tendency of the people to seek further information on the subjects such as is evidenced by an increase in the number of consultations at the clinics, a demand for more literature and more talks, and in the case of child welfare work, a subsequent decrease in the local loss of child life. Literature for free distribution. There is a lai'ge amount of literature giving the latest scientific informatio.n regarding health conservation which is available for irov distribution. Federal, State and municipal departments of health and education, insur- ance companies, philantliropic, religious and scientific organiza- tions have carefully prepared material, not only circulars, pam- ])li]('ts and ))()s1('rs for this purpose, ln;t also films and stereopticon slides, A\hich are loaned without charge. Much scientific knowl- edge of lhis sort finds its way to the people in pamphlet form before it is published in books. For driving home the lesson in any given locality in such fashion as to secure communitN' action, live facts concerninsx that Public Health NuRsr^'G 155 particular place should be presented. To do this charts have been found a good means of visualizing the situation. Charts and chart making. The equipment necessary in pre- paring charts suita])le for small exhibits, for lecture use or other purposes is simple. Bristol board of a creamy tint can be pur- chased at almost any stationery store and, in lieu of any other material, common wrapping paper is sufficient. Given a yard stick and a supply of soft crayons or pencils, almost anything in the line of a chart can be prepared. The most common faults of charts are that they are too small, that the lines are not heavy enough and that the data is not presented in its simplest or most attractive form. Charts should be at least 20x25 inches in size and the lines of the drawings should have a width about equal to the thickness of a half dollar. ^Yhether or not a chart will lie legible to a small audience can be determined by holding the chart at arm's length and examining it through half-closed eyes. If the lines then stand out boldly, they will be visible to the ordinary assembly. A point to remember in the making of charts in colors is to restrict the colors to three — black, green and red. Black is a neutral color, and should be used for general titles and outlines. Green, being the color usually associated in the mind with safety, and red being used to signify danger, these colors may best be utilized to indicate favorable and unfavorable conditions respectively. Therefore, in presenting a chart which will con- trast lives lost with lives which might be saved, put the titles in black, the graph expressing the number of lives to be saved in green and the column or other " graph " expressing the number of lives lost in red. There are three general rules in regard to charts which must be borne in mind by the one preparing them. These rules, like the point in regard to use of colors, are not easy to explain, but have been developed through years of preparing graphs and may be said to be based upon the psychological effect observed when pre- senting the charts to audiences of varied composition. These rules are: 1 Charts of a single dimension are the least likely to be misinterpreted. 156 State Departmeivt of Health 2 The general arrangement should he from left to right, as one liolds the chart before him or faces the chart. 3 The title must be so complete and clear that misinterpreta- tion will be impossible. For the purposes of the nurse, five forms of graphs or charts may be considered. First in importance is the spot map ; second, the horizontal and vertical bars; third, the curve; fourth, the circle with sectors and, fifth, the organization chart. The spot map is the easiest chart to prepare and, for many pur])oses, is the most convincing. There are few cities or large municipalities which do not have upon file in their department of pulilic works or engineering blue prints of the city or village. Blue or white prints of these maps usually may be secured at no or slight cost. The so-called white print is the most desirable, for in this all lines appear in dark blue or black against a white background, while in the ordinary blue print the lines are white against a blue background. In preparing a spot map, one needs only accurate morbidity or mortality statistics. For the small city or community, it usually is desirable to take statistics for a term of years. The extent of tuberculosis in a rural county is likely to appear negligible if based upon a single year, while for a period of five years the number of " spots " will convey a much more convincing impression. The " spots " may be put on with a soft pencil or ink ; tiny pasters or pins may also be used. The horizontal and vertical bar is extremely simple to use in a chart and is scarcely second in effect to the spot map. For many purposes it is superior to any other form of chart. For instance, it may be essential to convey the fact that the infant mortality problem is a "one wnrd problem," and the relative height of the bars, with the addition of the exact figures at the top of each liar, will bring the fact home conclusively. Keference to annual reports of the State Depnrtment of Health w'ill show many examples of the use of the bar graph and illustrate how^ simple is its adaptation to the presentation of statistics. The curve holds a peculiar place in the family of gi-aphs, for while it is extremely simple to construct, it is many times open Public Health NuRsnvG 157 to error in its interpretation by the layman. It therefore requires explanation to avoid misinterpretation. It is usually adaptable to charts where one wishes to show the incidence of disease or the development of an epidemic. In preparing curve charts, it is well to have the vertical guide lines accurately spaced so as to represent a certain passage of time — days, weeks, months or years. This permits of accurate charting and, if the lapse of time is cut down to weeks, will bring out facts regarding the development of an epidemic not available otherwise. The average nurse seldom will wish to use the circle with sectors, not only because its construction requires familiarity with certain mathematical formulae, but also because it must be handled with nicety to make accurate impressions upon a lay audience. A forceful variation of this form of graph is in the use of a circle within a circle. A circle may be drawn to represent the total number of deaths from all causes and at all ages in a city for a given year. The size of the circle is determined by the usual mathematical formulae for calculating areas. A second circle is then prepared, to be drawn in the center of the other. This, for example, may represent the number of deaths under one year of age. The result, if the smaller circle is blocked in with red, is to secure a fair representation of a target which, with a slogan such as " HIT THE BULLSEYE IN GREENWOOD,^' provides a striking chart for educational use. The organization chart is used where it is desirable to show how community activities may be coordinated and simplified. Such charts are widely used by research workers to indicate lax or complicated methods of city government, and while not always adaptable to the use of the nurse in health work, are of enough importance to justify a brief description. For example, a nurse may find that the existing public health nurses are not working in cooperation. A city may have a tuberculosis nurse, a school nurse, a charity nurse, an infant welfare nurse, etc., and yet no provision for interchange of ideas or information. A simple chart showing the tangled skein of activity, comparing it with the direct plan desirable, will convince the group of officials who may be too prone to let things go on undisturbed. 158 State Depaktimknt of Healtit The third type of piil)lic health education finds its field in the clinic and the home. It is that personal education through contact with teachers, physicians, nurses and social workers in school- room, clinic and home, an increase in the demand for which deter- mines largely the success of the other two methods, and creates a need for their modification. In this education process, teacli- ers, physicians, nurses and social workers are learners as well as instructors, and the rapid development of health conservation as a pul)lic concern in any community will depend as much upon the o])en-minded sincerity of this latter group as upon other factors. It is only through conference, team-work and readjustments of policy that health work keeps up with the needs of the times. In their work on Dispensaries, Davis and Warner specify that " the key to successful guidance of policy and administration in any organization is to bring together those who know the facts on which judgTuent should be based with those who need to know the facts in order to fi'ame judgment." Not until individuals and organiza- tions recog-nize how much each has to contribute to the knowledge and efiiciency of the other, and how great is their interdependence for successful progressive health education will these movements span the chasm existing between the need of the individual and available resources for the maintenance of health. Knowledge and deftness in application of the knowledge are necessary either in clinic, group relations, or home service. Indus- try emphasizes the personality of the worker in relation to his task as a matter for careful consideration in employing him for health education work. An acceptable personality added to knowl- edge of health conservation measures obtainable or creatable, and a habit of studying the ])sychology of the crowd and the individual are qualifications necessary for a leader who would ])roduce among workers of the world a determination to attain health for themselves and their families, to create a supply of health resources e(]ual to the demand and to materially increase the health and the happiness of the jniblic generally. In this intimate personal education work the i)ublic health nurse should he g'uided by good ])edagogical methods. For the nurse to do the thing herself exce})t as a d(>monstration is not teaching. Only as she succeeds in aiding the individual to adopt PuBi,ic Healti{ Nurskno 159 good hygienic habits, to maintain a hygienic environment and to become an ally in promoting pul)lic health can her work be deemed educational. Bed-side nursing is one thing ; it involves correction of conditions which the individual can not himself correct; it is essen- tial as a factor in promoting public health. Teaching others to become proficient in health maintenance is an entirely different process. For this reason not every good nurse is a good public health nurse. The success of any given public health nurse must be gauged by what her pupils learn to do for themselves and how keenly they utilize what they learn, rather tlian by what the nurse herself can do. If her work is good the pupils tend soon to gradu- ate from her tutelage, although if they have found her a good instructor they will be found returning for her counsel and guidance and bringing to her others in need of the same sort of instruction. i60 State Department of Health CHAPTER Xni What the Nurse Should Know about Vital Statistics It is perhaps unfortunate that to the average mind mention of vital statistics suggests a large array of figures and tables, intel- ligible only to those who have been specially trained in this line. A better conception is that vital statistics are statements of facts ; the facts of human life. If this idea is once firmly fixed in the mind of the reader the subject immediately becomes more interesting and more easily understood. There are three important divisions of vital statistics. These are the 1 Births 2 Marriages 3 Deaths Some authorities also include divorces, but these are rarely included in any state reports. . Stillbirths are not tabulated either as Ijirths or deaths, but under a separate classification. The law requires that in the case of a stilll)irt]i both a birth and death certificate shall be filed. A still- birth should not, however, be confused with a living birth, no matter how short a time the child may live. If there is any respiration it is a living birth and not a stillbirth. The distinction, however, between a stillbirth and an abortion or miscarriage is somewhat more difficult, but if the period of uterogestation is as much as five months it should be treated as a stillbirth and reported as such, and both a birth and death certifi- cate should be filed. The first important facts to know in studying the vital statistics of any community relate to the population; — First, the number of people in the area to be studied. Second, the composition of the population by sex and age, — namely, the number of males and the number of females; the number of young children and the number of very old people. The color is important where there are sufficient negroes to affect the rate, as the negro death rate is always very much higher than the white. I Public Health Nursing 161 The death rate for very young children and for very old people is very much higher than it is for those in the adult age groups and, consequently, the population in these two groups as com- pared to the middle adult group is exceedingly important. ' Estimates of the number of the population of any city, county or State for any year between censuses are commonly made by what is known as the arithmetical method. This method assumes that the rate of growth during the present censal period will be the same as for that immediately preceding. To illustrate: The city of " K " had a population June 1, 1900, of 43,872, and on April 15, 1910, of 50,982; what would be the estimated population July 1, 1915 ? (Operation) Elapsed time, June 1, 1900, to April 15, 1910 — 118yo months. (Pop. 1910), 50,982— (Pop. 1900), 43,872 — 7,110 gain for 1181/2 months. 7,110 -T- II8V2 = 60 gain for each month. Elapsed time from April 15, 1910, to July 1, 1915 = 621/2 months. 60x621/2+ (Pop. 1910), 50,982=^54,732 estimated popula- tion July 1, 1915. For statistical purposes, the midyear population is always used. It does not require a second thought to realize that the popula- tion of a pioneer country, made up almost entirely of vigorous, rugged men in the prime of life, would tell a very different vital statistics story from a community made up largely of children and old people and from which the healthy adult men and women had emigrated. What is termed the natural growth of any community is the number of births less the number of deaths. Where the births and deaths are equal the population is stationary,* but even in these days of exceptionally low birth rates, in most parts of the United States the birth rate is usually at least one and one-half times the death rate. Most communities of the United States are also affected very largely by immigration and emigration. This important factor • In France for a number of vears before the war the births and deaths were almost equal and the population was practically stationary. 6 162 State Department of Health depends upon many different things, but very largely upon indus- trial and agricultural conditions. The effect of marriage, and particularly the time of marriage, upon the movement of a population, is manifest. It is an axiom that delayed marriages result in small families; consequently any- thing that defers marriage, be that condition economic or socio- logic, directly affects the movement of population. There are many other factors which directly, or indirectly, affect this movement, but it seems unnecessary to discuss them in great detail at this time. Rates The births and deaths in a community are usually expressed on the basis of the number of births or deaths per thousand popula- tion. For instance, in a city where the population was 10,000 and there were 250 births, the birth rate would be expressed as 25 per 1,000; if there were 150 deaths, the death rate would be expressed as 15 per 1,000. These are what is known as crude or general rates, the term crude being the one more commonly used, and it applies simply to the total number of births or deaths in relation to the whole population. This will always be the first expression of a community rate, but it is subject to many refine- ments, which will tend to make one locality more accurately com- parable with another. Some statisticians refer to the science of statistics as the science of comparison, and the primary purpose of figuring rates of any kind is for this purpose; it would mean but little to say that the death rate of New York was 15 per thousand if we did not know the rates of other states or countries, but in order to make rates of value for the purpose of comparison great care must be exercised to sec that they are really comparable. Professor Whipple cites the following incident as illustrating the danger of erroneous comparison. During the Spanish-Ameri- can War one of the New York papers printed a stoiy in which it was shown that the death rate in the United States Navy at the time of war was 9 per 1,000, whereas the rate in New York City was 16 per 1,000, giving the impression that it was safer to be a sailor in the United States Na\'y in war time than it was to live in New York City. Public Health I^ursing 163 No consideration was made of the fact that in the United States IvTavy the personnel was composed of men between 18 and 45 years of age, selected after a rigid physical examination (eliminating all the weak) , living an outdoor life under the most hygienic sur- roundings, well fed and with every possible care exercised to reduce the possibility of sickness or death from disease; whereas m New York City we find every possible element of a population — the sick and the well, the infant and the octogenarian, the palace and the slum, the clean living and the dissipated. Cer- tainly a moment's thought will show that such a comparison means little. When we consider rates as applied to a particular class of the population, we make what is known as specific death rates. The death rate among males is usually higher than among females, and when a rate is made by taking the number of deaths of males in comparison with the number of the male population and the num- ber of deaths of females in comparison with the female population we have made a specific death rate for sex. If we figure the number of deaths of negroes, Mongolians or Indians as compared with the number of negroes, Mongolians or Indians in the population we have then made a specific death rate for color or race. When we figure the number of deaths of children under one year of age as compared with the population under one year of age or the number of deaths in each age group, compared with the number of people in each age group, we have then made a specific death rate for age. Specific death rates for disease are exceedingly important and are usually figured on a basis of the number of deaths from any given disease per 100,000 of the population. It is by this means that we are able to compare in a measure the healthfulness of a community. If, for instance, we find that the specific death rate for typhoid fever is much higher in one locality than in another, it indicates what Rosenau describes as " a sanitary short circuit " and suggests a very careful survey of those conditions which are known to produce typhoid fever. If the specific death rate from diarrhea and enteritis in children under two years is higher than 164 State Department of Health it should be, it indicates the necessity of very definite work in regard to milk suj)ply and the better education of mothers in the care of their babies. Morbidity statistics are the statistics of sickness and should not be confused with mortality statistics or statistics of death. Unfor- tunately, perhaps, the average American citizen objects to inquiry in regard to his health, and the State, therefore, does not collect any records of sickness except those toward the prevention and control of which public measures are directed. Morbidity rates are usually expressed in the number of cases per 100,000 population. The fatality rates of a disease refer to the percentage of the cases which prove fatal. Specific death rates are valuable for many comparisons and are frequently used. For the purpose, however, of a general com- parison as between communities another form of rate is used which is called a corrected or standardized death rate. These are described by the United States Bureau of the Census as follows : " The term ' corrected rates ' is employed to signify a rate in the computation of which allowance has been made for difference in age and sex constitution of the population. When obtaining corrected death rates the usual method is to select a standard population, definitely distributed into certain groups with respect to age or age and sex. The specific death rates of any area as computed for the same groups are then applied to corresponding subdivisions of the standard poimlation, the result being the number of deaths which would have occurred in each grouj) of the stand- ard population had its death rate been the same as that of the same group in the given area. The summation of the deaths that would have occurred in all the groups of the standard poinilation gives the total number of deaths in the standard pojmlation corresponding to the observed specific death rates in the given area, and the division of this total by the standard population yields the corrected death rate." Public Health Nursing 165 The standard population which has been generally accepted by registration officials within the past few years is the standard mil- lion of England and Wales, as shown by the census of 1901 and is appended herewith. Standard Million, England and Wales, 1901 Age Period Both Secoes Males Females All Ages 1,000,000 483,543 516,467 Under 5 years 114,262 57,039 57,223 5-9 years 107,209 53,462 53,747 10-14 years 102,735 51,370 61,365 15-19 years 99,796 49,420 50,376 20-24 years 95,946 45,273 50,673 25-34 years 161,579 76,425 85,154 35-44 years 122,849 59,394 63,455 45-54 years 89,222 42,924 46,298 55-64 years 69,741 27,913 31,828 65-74 years 33,080 14,691 18,389 75 years and over 13,581 5,632 7,949 The infant mortality rate is perhaps less understood than any other form of rate. The infant mortality rate is the comparison of the number of deaths of children under one year of age with the number of births which occurred during the same period, and is expressed in the number of deaths per thousand births. This, obviously, has nothing to do with deaths at other age periods. This rate is frequently unreliable because births in many localities are not all reported, and if even a few births are unreported in a community and the deaths are all reported it makes the rate appear higher than it really is. In the consideration of the infant mortality rate, then, it is essential to carefully study the birth registration of the com- munity and thus be assured of its completeness before an attempt is made to determine an infant mortality rate. Marriage rates are usually expressed in the terms of the number of marriages per 1,000 population. Some authorities prefer, however, to express the number of people married per 1,000 popu- lation, which rate is just double the foregoing. To understand vital statistics it is essential that we understand the laws under which they are collected. 166 State Department of Health In this State the law provides for a system of local registrars, one in each city, village and town and state hospital, charitable, or penal institution. In all there are 1,485 registration districts. In the case of birth the law requires a certificate, fully and com- pletely made out, to be filed with the local registrar within five days by the physician or midwife in attendance, and the law pro- vides a heavj penalty for failure so to do. If there is no attend- ing physician or midwife the law fixes the responsibility upon the father, mother, or householder, in the order named. In the case of death the law requires that the undertaker shall fill out a death certificate, securing the infonnation as to the name of the decedent, the sex, color, conjugal condition, date of birth, age, occupation and birthplace, name and birthplace of father, maiden name and birthplace of mother, and that he shall cause the certificate to be signed by the informant from whom he obtains this information. He must then present the certificate to the physician last in attendance on the case, who must state the time of his attendance, the cause of death and its duration, the contributory cause, if any, and its duration, and must sign and date the same. The undertaker then states the place of burial, or removal, and the date thereof, signs and presents the completed certificate to the local registrar, in exchange for which he receives a burial, or removal permit. A heaAy penalty attaches to the burial, removal or other disposition of a dead body without first receiving a permit for so doing. Penalties are also provided for the sexton or person in charge of any cemetery who permits an interment without a burial permit being presented to him. The local registrars, after duly entering the certificates received in their own records, send the original certificates of both births and deaths to the State Department of Health, where they are classified, indexed and filed as a permanent record. Certifi- cates of birth for school and work purposes and copies of death records for insurance, pension and other legal purposes are issued on request. There are three important reasons why births and deaths should be registered. These are set forth by the Bureau of the Census a* follows : Public Health Nursing 167 First, the protection of the rights of an individual and of the community (legal use) ; Second, the protection of the lives and the health of the people (sanitary use) ; Third, the knowledge of the movement of population (demo- graphic use). The prompt registration of births provides a legal record which is of value to the child in many ways ; for instance, it protects not only the child in its education hut also the educational institutions, because with the positive evidence of the age of each child it is not possible to use the schools as a nursery by sending children at an age when the mind is not sufficiently developed to permit its being taught. Again it insures that the child shall not be with- dravni from school until those years have elapsed which the law requires shall be given over to education, and the child can not, therefore, be forced to work by parents who desire to exploit its wage-earning power. The child as a potential citizen is protected in its rights of citizenship, in the right to vote, in the right to inherit and many other important ways. From a sanitary standpoint we can not hope to reduce the awful life waste caused by infant mortality unless we know where the babies are and can promptly put into the hands of mothers, where it is needed, prompt and proper instruction. The registration of deaths is important for many legal reasons, as well as for the purposes of insurance, inheritance, and succes- sion. "We are more familiar, however, with the sanitary reason for death registration, as it enables us promptly to find the plague spots and to take measures to eradicate them. We can not success- fully fight disease if we do not know where it is and what havoc it is causing. The demographic reason for the registration of both births and deaths is that we may understand the movement of population, the sources from which it is being renewed and the causes of its depletion. IN'ONRESIDENT DeATHS If it is desired to study some city closely, allowance may be made for what is known as nonresident deaths. Where there are 168 State Department of Health considerable hospital facilities in a city, or where there may be a public institution where people are comnutted by process of law, or where they resort for treatment of disease, this may be a marked factor in producing a high death rate. In those cases the non- resident deaths may be omitted and the true death rate for resi- dents only be thus determined, but Avhen this is done the com- parative value of the rate is vitiated, as it would be misleading to compare this with any other city where the rate had not been similarly treated, as almost eveiy city has some hospitals and some nonresident deaths. If it is desired to compare the relative healthfulness of two cities, however, the elimination of nonresident deaths from both will aiford valuable data for detailed study. It is a difficult problem to attempt the general omission of non- resident deaths and their reassignment to other localities, and until more definite procedure has been agreed upon by registration officials, it is best to confine such action to special studies of restricted areas. Perhaps the practical use of vital statistics may be sho"^ii in the following study which was undertaken to demonstrate the value to the community of public health nursing as a whole, and in par- ticular, the employment of a special baby nurse. In a city which had a population of about 50,000, the study was made to cover the months of May, June, July and August in the years 1913 and 1914, and included only the deaths of children under two years of age. Total Deaths Four Months 1913 53 1914 34 Gain 35 . 8% Months of Occurrence 1013 1914 May 10 9 June 6 6 July 10 8 August 27 11 Public Health Nursing 169 The Causes of Death Diarrhea and enteritis Congenital debility Premature births Other diseases of early infancy Convulsions of infants Bronchitis Tubercular peritonitis Whooping cough Bronchopneumonia Malaria Cerebrospinal meningitis Tetanus Congenital malformation Purulent septicaemia Measles Food poisoning Violence Ages Under 1 week Over 1 week and under 1 month Over 1 month and under 6 months Over 6 months and under 1 year One to two years 1913 1914 28 4 6 11 4 4 3 2 1 1 1 2 3 2 2 1 1 1 3 1 2 1 1 2 1913 1914 14 10 3 4 14 7 13 4 9 9 An examination of the causes of death will immediately reveal that this veiy remarkable improvement was due to a decrease in the number of deaths from diarrhea and enteritis from 28 to 4. In searching for some explanation of this reduction, it was discov- ered that the summer of 1913 was extremely hot while that of 1914 was quite cool. Under more favorable weather conditions, milk naturally was less quickly spoiled, children slept better and thus were able to build up a greater resistance to infection. It is therefore reasonable to suppose that cooler weather was an impor- tant factor in reducing deaths from this cause. A further survey of the situation revealed the fact that in 1914 the city had greatly improved its supervision of milk supplies and the quality of milk furnished throughout the city was far better than the preceding year. Milk stations had been established, and even the poorest persons were able to secure a high-grade milk for their babies. 170 State Department of Health Another imjjortant consideration was the fact that for the year preceding the summer of 1914 much had been done in the way of baby clinics and of general educational propaganda for the insti-uc- tion of mothers in the general care of their babies. These three elements, together with the work of the nursing association, were probably in a large measure responsible for the reduction of this loss of life. It will be observed by comparison of the age tables that the entire saving occurred among babies under one year of age, the deaths between one and two years being the same in both years. It will be noted, however, that in the three causes, congenital debility, premature births and other diseases of early infancy, there were 13 deaths reported in 1913, whereas there were 15 in 1914. The reduction in deaths from these causes is generally con- ceded to be a problem of prenatal work, and it is evident that but little had been done, at least successfully, in this regard during this period. This little study and these comments are submitted simply to show that the vital statistics open the way for a study of those social and medical elements which largely affect the death rate. Caution Great care should always be exercised not to be misled by con- clusions or rates based upon a small population or a small number of incidents. A health officer of a small community was much disturlied when informed by one of his friends, as a joke, that 50 per cent of the deaths in his district during the preceding month were caused by {ippendicitis; after some excitement he discovered that there had been two deaths, one of which was from that disease. Death rates based upon a small population or a short period must be carefully used or the results will be misleading. Criticism is occasionally made of the publication of monthly birth and death rates, and this is usually because the purpose of 80 doing is not generally understood. The fluctuation of the monthly death rate is usually due to some unusual epidemic or catastrophe, and is, therefore, an indica- Public Health ISTuksing 171 tion of danger, calling into action those forces provided by law to prevent undue loss of life from any cause. Obviously there can be no possible connection between these monthly rates and the annual rates as exceptional months are frequently compensated in fol- lowing months. In every community, there are always a number of people of great age or invalids who might, under favorable con- ditions, linger for months on the brink of the grave, but a marked thermal change, or an epidemic of some kind, such as measles, whooping cough, influenza or grippe, will prove too much for their weakened resistance and the death rate goes up accordingly. A health officer should leam to read the death rates in his com- munity as a mariner reads his barometer, and be prepared to battle with the elements that destroy life. In a large area, such as the State of New York, slight changes do not make notable fluctuations in the death rate. It takes an increase or decrease of 858 deaths in a month to increase the monthly death rate one unit, or from 15.0 per 1,000 to 16.0 per 1,000 or decrease it to 14.0 per 1,000. In a small conmiunity the changes are much more marked. In Niagara Falls, with a population of 44,585, the number of deaths varied in 1916 from a minimum of 33 in November to a maximum of 85 in May, and the death rate for these months from 9.0 to 22.5 per 1,000. In that city a change of four deaths in a monthly rate would have made a difference of 1.3 or from 14.0 to 15.3 per 1,000. In Lock- port, with a population of 18,833, the numl)er of deaths varied in 1916 from 19 with a death rate of 12.3 in June to 30 with a death rate of 18.8 in January. Here an increase of one death would have increased the rate from 18.0 to 18.9 per 1,000. Great care must be taken to avoid error in the intei-pretation of these rates, particularly when applied to a small population. If it is desired to determine the annual rate instead of the monthly rate, this may be done by adding the number of deaths in any month to the eleven preceding months and dividing the sum by the population. This gives an annual rate based upon the assumption that the number of deaths for the balance of the year will equal the number for the same period of the preceding year. The monthly rates and the annual rates are two different things 172 State DErAHTMENT of Health and should be used for different purposes. The sharp fluctuations which may occur in monthly rates are typical of acute disease con- ditions. It is probable that in many cases by the time these rates are published the cause of the sharp increase has been removed or is under control. On the other hand, a slowly increasing annual death rate compared month by month is typical of what might be termed a chronic condition, and means that there is some disturb- ing element at work that should be sought out and corrected. Public Health Nursing 173 CHAPTER XIV The PubUc Health Nurse and Child Welfare Activities There is no more important field of activity on the part of the public health nurse than that which pertains to the prevention of disease and of deaths among infants and young children. Child welfare work has assumed a greater importance than evei- since the World War, for the protection and conservation of childhood is not alone a home problem but is one that affects the community and the nation. The public health nurse should be prepared to supervise the health and surroundings of the child from the earliest prenatal through the adolescent period. The infant mortality rate is the comparison of the number of deaths under one year of age with the number of births which occurred during a given year, and is expressed in the number of deaths per thousand births. Stillbirths, which constitute about 4 per cent of all births, are not included in those used in computing infant mortality although both a birth and a death certificate are required to be filed. If a baby breathes after birth it is not a still- birth. To obtain the infant mortality rate, divide the number of deaths under one year of age during the year by the number of births occurring during the same period and multiply by lOO'O. For example, — a city has 250 births in one year and 30 deaths under one year of age. — X 1000= 120 25D The infant mortality rate is 120 per 1000 living births. Before undertaking a health program for any community, then, one should know its infant mortality rate. One should also know in what direction it is tending. A community may have an infant death rate which is not high, and yet it may be slowly rising. Such a condition should lead to a study of the causes pro- ducing it in order that they may be corrected. Sir Arthur Newsholme states that " infant mortality is the most sensitive index we possess of social conditions and a high 1Y4:' State Department of Health death rate among the babies indicates conditions which affect not alone the little children but the entire community." A large per- centage, possibly one-third, of infant deaths can be prevented. Why, if preventable, are they not prevented ? To answer this question intelligently one must know where and why the babies die and for this information recourse to vital statistics must he had. A study of the causes of deaths in the first year of life reveals many interesting facts. Nearly one-half occur within the first four weeks after birth and the number of deaths then diminish month by month. The deaths which occur in the first month include those due to congenital malformation, debility and prematurity, and are the result of conditions which affect the child before it is boi-n. Since it has been shown through a careful study of statistics that nearly one half of all infant deaths occur during the first month of life it is obvious that if the baby welfare service is going to have a chance at saving these lives it must find some way to give care to the mother during her entire pregnancy. This care cannot be given to a gi'oup; it must be individual care. As it has been found that it is practically impossible to get any con- siderable number of prospective mothers to attend clinics or to consult a physician upon invitation, child welfare organizations have sent nurses to homes of enciente women to get them under the care of a physician. This method is found to produce results. The nurse may meet with little response during her first visits ; here as in other fields personality is a large factor, but if the nurse is enthusiastic over child-saving and at the same time tactful she will find that a large proportion of the prospective mothers will ultimately be persuaded to accept her recommendation. Quite recently the Children's Bureau of the U. S. Department of Labor has published the " Minimum Standards of Child Wel- fare" adopted by the Washington and Eegional Conferences on '^hild Welfare. The following extract is taken from their Bureau Publication No. 62 : Public Health Nursing 175 " Minimum Standards for Public Protection of the Health OF Mothers and Children Maternity " 1 Maternity or prenatal centers, suflScient to provide for all cases not receiving prenatal supervision from private physi- cians. The work of such a center should include : (a) Complete physical examination hy physician as early in pregnancy as possible, including pelvic measure- ments, examination of heart, lungs, abdomen, and urine, and the taking of blood pressure; internal examination before seventh month in primipara; examination of urine every four weeks during early months, at least every two weeks after sixth month, and more frequently if indicated ; Wassermann test whenever possible, especially when indicated by symptoms. (b) Instruction in hygiene of maternity and supervision throughout pregnancy, through at least monthly vis- its to a maternity center until end of sixth month, and every two weeks thereafter. Literature to be given mother to acquaint her with the principles of infant hygiene. (c) Emplo}Tnent of a sufficient number of public health nurses to do home visiting and to give instructions to expectant mothers in hygiene of pregnancy and early infancy ; to make visits and to care for patients in puerperium ; and to see that every infant is referred to a children's health center. (d) Confinement at home by a physician or a properly trained and qualified attendant, or in a hospital. (e) Nursing service at home at the time of confinement and during the lying-in period, or hospital care. (f ) Daily visits for five days, and at least two other visits during second week by physician or nurse from maternity center. 1Y6 State Department of Health " (g) At least ten days' rest in bed after a normal delivery, with sufficient household service for four to six weeks to allow mother to recuperate, (h) Examination by physician six weeks after delivery before discharging patient. " Where these centers have not yet been established, or where their immediate establishment is impracticable, as many as possi- ble of these provisions here enumerated should be carried out by the community nurse, under the direction of the health officer or local physician. 2 Clinics, such as dental clinics and venereal clinics, for needed treatment during pregnancy. 3 Maternity hospitals, or maternity wards in general hospitals, sufficient to provide care in all complicated cases and for all women wishing hospital care; free or part-payment obstetri- cal care to be provided in every necessitous case at home or in a hospital. 4 All midwives to be required by law to show adequate training, and to be licensed and supervised. 5 Adequate income to allow the mother to remain in the home through the nursing period. 6 Education of general public as to problems presented by mater- nal and infant mortality and their solution. " Infants cmd Preschool Children 1 Complete birth registration by adequate legislation requiring reporting within three days after birth. 2 Prevention of infantile blindness by making and enforcing ade- quate laws for treatment of eyes of every infant at birth and supervision of all positive cases. 3 Sufficient number of children's health centers to give health instruction under medical supervision for all infants and children not under care of private physician, and to give instruction in breast feeding and in care and feeding of chil- dren to mothers, at least once a month throughout first year, and at regular intervals throughout preschool age. This cen- ter to include a nutrition and dental clinic. Public Health Nursing 1'J"J' " 4 Children's health center to provide or to cooperate with suf- ficient number of public health nurses to make home visits to all infants and children of preschool age needing care — one public health nurse for average general population of 2,000. Visits to the home are for the purpose of instructing the mother in — (a) Value of breast feeding. (b) Technic of nursing. (c) Technic of bath, sleep, clothing, ventilation, and general care of the baby, with demonstrations. (d) Preparation and technic of artificial feeding. (e) Dietary essentials and selection of food for the infant and for older children. (f ) Prevention of disease in children. 5 Dental clinics ; eye, ear, nose, and throat clinics ; venereal and other clinics for the treatment of defects an.d disease. 6 Children's hospitals, or beds in general hospitals, or provision for medical and nursing care at home, sufficient to care for all sick infants and young children. 7 State licensing and supervision of all child caring institutions or homes in which infants or young children are cared for. 8 General educational work in prevention of communicable disease and in hygiene and feeding of infants and young children." Infant mortality and sociology are closely related. The prob- lems of how to deal with ignorance, inexperience and poverty, how to restrict the emplo}anent of women during the period of child bearing, how to care properly for the mother who is unmar- ried, how to provide proper facilities especially needed in rural districts at confinement, and how to secure better housing and living conditions for working people must be met if the number of deaths of infants during the first four weeks is to be materially reduced. Deaths from gastrointestinal diseases have been materi- ally reduced by teaching and assisting mothers to breast-feed their babies, to guard them against the fonns of danger the imminence of which is announced by the presence of flies, and to provide them with proper conditions for tranquil sleep in properly sheltered and ventilated places. 1Y8 State Department of Health There is great need for intensive education of mothers and others concerning the danger frorii the common cold, the impor- tance of early treatment therefor, and the necessity of preventing snch infection by avoiding contact with |x;rsons having even slight colds. A careful analysis of the causes that affect the lives and health of children shows the largest factor to be ignorance on the part of the mother. The solution of the infant mortality problem lies in the education of the mother both in the care of herself and her baby. The most effective method of combating this ignorance is b}' means of what are now kno^\^l as child welfare stations. The work of these stations is preventive and the aim is to educate, and not to treat disease. They are welfare centers for well babies, and the object is to keep them well. The main functions of a child welfare station may be outlined briefly as follows : To advise and instruct mothers in the care and feeding of babies ; To encourage and prolong breast feeding ; When artificial feeding is necessary, to see that clean, pas- teurized milk is provided, to prescribe suitable mixtures and to insure the proper preparation of the food by the mothers in their own homes ; To teach mothers how to prevent many of the diseases of childhood due to exposure and errors in diet ; To assist in the care, instruction and preparation of the expectant mother; To supervise the homes and surroundings of boarded out children ; To care for children in the preschool age ; To maintain a place where mothers will come with their troubles and receive sympathetic and intelligent advice. The child welfare nurse is the most important factor in the success and usefulness of the station. She must have tact, per- severance and the genuine art of leadership among mothers and children. Some of her duties may be enumerated as follows: At the station she interviews the mothers and prepares the babies for examination. She keeps all the records and weighs Public IIealtk Xursing 179 the babies. She arranges for the lectures and talks and gives practical demonstrations. At the homes she sees that the instrac- tions of the physician ai-e carried out. She instructs the mothers in their own homes how to clothe, care for and feed the baby. When the physician finds defects in older children, such as enlarged tonsils, adenoids, decayed teeth, spinal curvatures, etc.,- the nurse goes to the homes and sees that these defects are remedied and that proper hygienic and medical treatment is given. Provisions for extending relief to needy cases should be admin- istered by the nurse, who should be familiar with all the condi- tions. She should know the philanthropic and relief agencies of the city and keep in touch with them. She should have tact and delicacy in inducing people to use needed public and private agencies for better health conservation. The nurse should have knowledge of the care of pregnant women so that she can give advice and counsel. The nurse should visit the homes and urge mothers to attend the clinics so that the physician may make exam- ination of the urine, test the blood pressure, etc. She should instruct the mothers in the hygiene of pregnancy and early infancy, provide for confinement in a hospital or at home by a physician, make daily visits for at least five days after confinement and two visits the second week and see that proper prophylactic treatment is given the eyes after birth. To secure early prenatal care for all prospective mothers it is essential that nurses establish friendly relations with all local midwives. Most of these women are amen- able to friendliness. If they learn that they may expect good faith from the nurse they will in many instances accept her instruction and advice. The nurse should arrange to be at the station at a stated hour each day so that she can be reached by the mothers. In the absence of practical instruction of girls in infant care in our public schools the public health nurse should be competent to furnish this instruction in classes at the welfare station. This sort of instruction is now quite generally incorporated into the syllabus for classes in household arts and home making. The Board of Education in England made the following recom- mendations for instruction of young school girls in infant care and management: 180 State Department of Health " At the end of a course in infant care, each girl when she leaves school ought to know how to wash and dress a baby ; what clothes it should wear and how to make them; the advantage of natural over artificial food ; how much cow's milk a baby requires and how exactly its ' bottle ' should be prepared at, say, three, six and nine months of age ; how to feed a baby ; how to prepare barley water and whey ; when the infant may first have solid food, and the character of such food; why patent foods should not be given; what are the signs of indigestion (such as vomiting, diarrhea, constipation or wasting), and why it is important to pay attention to such s^Txiptoms ; how much sleep is required ; how to provide a comfortable and suitable cradle; why fresh air and sun- shine are needful, and what is the danger from draughts and cold; how to teach a baby cleanly and desirable habits ; why a ' com- forter ' should not be used ; and generally how the hom-e manage- ment should be undertaken. '' In all this but little mention need be made of disease and illness. It is not desired to teach every school girl a hotch-potch of semi-medical information on the various ailments and diseases to which infancy is liable, but to give her a simple and practical understanding of those things which make up a healthy home life for little children." The child welfare nurse should have a working knowledge of food values and dietetics for young children. She should be com- petent to outline special diets and to demonstrate in the mother's kitchen how the foods are prepared. She should know the faulty health habits that produce malnutrition and undernourishment. All children, both in the preschool and the school period, should be weighed at least once a month and measured at least twice a year. The ratio between the height and weight is more important in determining the nutrition of the child than in comparing the weight and age as is usually done. The following table ])repared by Dr. Thomas Wood is recommended by the Child Health Organ- ization. If a child weighs seven per cent less than the average for its height it should be considered undernourished. Over- nourishment to the extent of 15 per cent over the average should be considered abnormal and be remedied by suitable diet, exer- cise and health habits. Public Health Nursing 181 EIGHT HEIGHT AND WEIGHT FOR GIRLS Height inches. 5 yrs. 6 yrs. 7 yrs. 8 yrs. 9 yrs. 10 yrs. 11 yrs. 12 yrs. 13 yrs. 14 yrs. 15 yrs. 16 yrs. y'l 18 yrs. 39 40 41 42 43 44 45 46 47 34 36 40 42 44 46 48 35 37 39 41 42 45 47 48 49 51 53 36 38 40 42 43 45 47 49 50 52 54 56 59 62 43 44 46 48 50 51 53 55 57 60 63 66 68 49 51 52 54 56 58 61 64 67 69 72 76 53 55 57 59 62 65 68 70 73 77 81 85 89 56 58 60 63 66 68 71 74 78 82 90 94 99 104 109 61 64 67 69 72 75 79 83 87 91 95 101 106 115 117 119 70 73 76 80 84 88 93 97 102 107 112 117 119 121 124 126 129 77 81 85 89 94 104 109 113 118 120 122 126 128 131 134 138 86 90 95 100 106 111 115 119 122 124 127 130 133 136 140 145 91 96 102 108 113 117 120 123 126 128 132 135 138 142 147 98 104 109 114 118 121 124 127 129 133 136 139 143 148 48 49 50 53 54 56 57 58 59 . . . . 60 106 61 HI 62 115 63. . 119 64 122 65 125 66 . 128 67 130 134 69 137 70 140 71 144 72 149 PREPARED BY DR. THOMAS D. WOOD. About what a girl should gain each month. AGE AGE 5 to 8 6 oz. 14 to 16 : 8 o«. 8 to 11 8 oz. 16 to 18 4 oi, H to 14 12 oz. Weights and measures should be taken withDUt shoes anJ In only th2 U3ual indoor clothes. 182 State Depaktment of Health RIGHT HEIGHT AND WEIGHT FOR BOYS Height inches. 5 yrs. 6 yrs. 7 yrs. 8 yrs. 9 yrs. 10 yrs. 11 yrs. 12 yrs. 13 yrs. 14 yrs. 15 yrs. 16 yrs. 17 yrs. 18 yrs. 39 40 41 42 43 44 45 46 47 35 37 39 41 43 45 47 48 36 40 42 44 46 47 49 51 53 55 37 39 41 43 45 46 48 50 52 54 56 58 60 62 44 46 47 48 50 52 55 57 59 61 63 66 69 49 51 53 55 58 60 62 64 67 70 73 77 54 56 58 60 63 65 68 71 74 78 81 84 87 91 57 59 61 64 67 72 75 79 82 85 88 92 95 100 105 62 65 11 73 76 80 83 86 89 93 97 102 107 113 74 77 81 84 87 90 94 99 104 109 115 120 125 130 134 138 78 82 85 88 92 97 102 106 111 117 122 126 131 135 139 142 147 152 157 162 86 90 94 99 104 109 114 118 123 127 132 136 140 144 149 154 159 164 169 174 91 96 101 106 111 115 119 124 128 133 137 141 145 150 155 160 165 170 175 97 102 108 113 117 120 125 129 134 138 142 146 151 156 161 106 171 176 48 49 60 51 52 53 . 54 55 57 58 60 61 110 62 116 63 119 64 122 65 126 66 130 67 135 68 139 143 70 147 71 152 157 73 162 74 167 76 . . 172 76 177 PREPAEKD BY DR. THOMAS D. WOOD. About what a boy should gain each month. AQE AOB 5 to 8. 8 to 12. 6 oz. 8 oi. 12 to 16. 16 to 18. Weigh on the same date each month about the same hour of the day. Public Health Nuksing 1S3 Health supervision and education of the school child in the State of New York is definitely assigned through legislative enactment to the State Department of Education. Yet school children are for the major part of their time outside of school control and in many conununities health work in the schools is undergoing very slow growth. It is therefore important that every public health nurse, especially those engaged in child welfare, should consider the life of the child in its entirety. For this reason the following minimum standards for the school and the adolescent child, which, with those previously quoted, comprise those estab- lished by the Children's Bureau, are here inserted. "Minimum Standards in Child Welfare for School Children 1 Proper location, construction, hygiene, ventilation, and sani- tation of schoolhouse ; adequate room space — no overcrowd- ing. 2 Adequate playground and recreational facilities', physical training, and supervised recreation. 3 Adequate space and equipment for school medical work and available laboratory service. . 4 Full-time school nurse to give instruction in personal hygiene and diet, to make home visits to advise and instruct mothers in principles of hygiene and nutrition and to take children to clinics with permission of parents. 5 Part-time physician with one full-time nurse for not more than 2,000 children; if physician is not available, one school nurse for every 1,000 children ; or full-time physician with two full-time nurses for 4,000 children for: (a) Complete standardized basic physical examinations once a year, with determination of weight and height at beginning and end of each school year; monthly weighing wherever possible. (b) Continuous health record for each child to be kept on file with other records of the pupil. This should be a continuation of the preschool health record which should accompany the child to school. (c) Special examinations to be made of children referred by teacher or nurse. (d) Supervision to control communicable disease. (e) Kecommendation of treatment for all remediable de- fects, diseases, deformities, and cases of malnutri- tion. 184 State Department of Health ''(f) Follow-up work by nurse to see that physician's recom- meudutions are carried out. G Available clinics for dentistry, nose, throat, eye, ear, skin, and orthopedic work ; and for free vaccination against small- pox. 7 Open-air classes with rest periods and supplementary feedings for pretuberculars and certain tuberculous children, and children with grave malnutrition. Special classes for children needing some form of special instruction due to physical or mental defect. 8 Nutrition classes for physically subnormal children, and the maintenance of midmorning lunch or hot noonday meal when necessary. 9 Examinations by psychiatrist of all atypical or retarded chil- dren. 10 Education of school child in health habits, including hygiene and care of young children. 11 General educational work in health and hygiene, including education of parent and teacher, to secure full cooperation in health program. "Adolescent Children 1 Complete standardized basic physical examination by physi- cian, including weight and height, at least once a year, and recommendation for necessary treatment to be given at children's health center, school, or other available agency. 2 Clinics for treatment for defect and disease. 3 Supervision and instruction to insure : (a) Ample diet, with special attention to growth-produc- ing foods. (b) Sufficient sleep and rest and fresh air. (c) Adequate and suitable clothing. (d) Proper exercise for physical development. (e) Knowledge of sex hygiene and reproduction. 4 Full time education compulsory to at least 16 years of age, adapted to meet the needs and interest of the adolescent mind, with vocational guidance and training. 5 Clean, ample recreational opportunities to meet social needs, with supervision of commercial amusements. 6 Legal protection from exploitation, vice, drug habits, etc." Public Health IsTuksing 185 CHAPTER XV Supervision of Midlives The following laws and regulations govern the practice of mid- wifery in the State of New York : Chapter 559, Laius of 1913. (§ 2-b Sanitary Code) :— The public health council shall have power by the affirmative vote of a majority of its members to establish and from time to time amend sanitary regulations, hereinafter called the sanitary code, without discrimination against any licensed physicians. The sanitary code may deal with any matters affecting the security of life or health or the preservation and improvement of public health in the state of New York, and with any matters as to which jurisdiction is hereinafter conferred upon the public health council. The sani- tary code may include provisions regulating the practice of midwifery. These regTdations are found in chapter IV of the sanitary code a copy of which may be obtained by applying to the State Depart- ment of Health, Albany, N". Y. The Penal Law, Section 482, Paragraphs 3 and 4 contain the following : A peison who: (3.) — Being a midwife, nurse or other person having the care of an infant within the age of two weeks neglects or omits to report immediately to the health officer or to a legally qualified practitioner of medicine of the city, town or place where such child is being cared for, the fact that one or both eyes of such infant are inflamed or reddened whenever such shall be the case, or who applies any remedy therefor without the advice, or except by the direction of such officer or physician; or, (4.) — neglects, refuses or omits to comply with any provisions of this section, ... is guilty of a misdemeanor. What the Midwife Must Do to Peactice She must : 1 Secure her license to practice from the State Department of Health, the license to be renewed on January first annually ; 2 Register annually her name with the local registrar of vital statistics in each municipality in which she desires to practice ; 186 State Depaetment op Health 3 File birth certificates within five days after birth with the local registrar of vital statistics of the place in which birth occurs ; 4. If a child does not breathe after birth (stillbirth), leave the birth certificate at the house and at once report the case by tele- phone, messenger, or in person, to the health officer. He will personally investigate, or send an inspector to do so, and will countersign the birth certificate and file it with the registrar. A midwife can not sign the death certificate for a stillborn child — this must be done by the health officer, or by a coroner or similar public officer if an inquest on the body is necessary, as provided by section 378 of the Vital Statistics Law; 5 Secure from the local health officer and keep on hand a suf- ficient supply of ophthalmia neonatorum outfits and make use of these according to directions, in every case; 6 Keep a record of births reported by her on the stub of her record ; 7 Comply in every respect with the rules and regulations governing the practice of midwifery. Penalties The penalty for violation of regulations of the Sanitarv^ Code (Chapter 1, Regulation 2) is: Any violation of any provision of this code is hereby declared to be a misdemeanor and is punishable by a fine of not more than fifty dollars or by imprisonment for not more than six months, or by both. The penalty for violation of health laws, (Section 1740, para- graph 2, Penal Law) is: A person who wilfully violates any provision of the health laws, or any regulation lawfully made or established by any public officer or board under authority of the health laws the punishment for violating which is not otherwise prescribed by those laws, or by tliis chapter, is punishable by imprisonment not exceeding one year, or by a fine not exceeding two thousand dollars or by both. The penalty for failure to report a birth in accordance with the requirements of the Vital Statistics' Law (Par. 392, Vital Statistics Law) is: Public Health Is^ursing 18T u * * * Whenever any physician, midwife, or other person shall fail or neglect to properly record and file a certificate of birth as required by this article, such person shall be liable to a penalt;y of not less than five dollars nor more than fifty dollars for the first and second ofi'enses, which penalty may be recovered by an action brought by the state commissioner of health in any court of competent jurisdiction, and for every subsequent offense, such person shall be guilty of a misdemeanor, punishable by a fine of not less than ten nor more than one hundred dollars, or by impris- onment for not more than sixty days, or both." Directions for the Inspection of Midwives 1 Visit each midwife at the address given upon the list fur- nished you. In case the midwife is out you should visit and revisit until she is found. If she has moved to a new address you should go to the new address. Ask the midwife to show her license, and see that the name and address correspond. If a midwife is married report to the Department of Health if the license does not contain her married name. 2 See that the midwife's sign corresponds with the name upon the license, and that there is no misleading information on her sign, card, advertisement, or any handbill. Copies of the three latter should be obtained. 3 Remember that the license is for one year only, and if it is to expire within a short time notify the midwife that she must obtain a new license from the State Department of Health. 4 Note the general character of the house in which the midwife lives. Note also the general condition of the home as to neatness and cleanliness. 5 Note the condition of the midwife's person — her clothing, hands and fingernails. The clothing should be neat and clean, and the hands and fingernails clean, smooth and short. 6 Examine the stubs of the midwife's records of births, and note whether or not they are properly kept and legible. Ascertain whether or not the midwife can read and understand a paragraph of the regulations, and whether she can fully fill out a birth certificate in her own handwriting. 188 State Department of Health 7 Inspect the equipment, and see if the following articles are in the midwife's bag : Nail brush Wooden or bone nail cleaner Jar of green or soft castile soap Tube of vaseline Clinical thermometer Agate or glass douche reservoir Two rounded vaginal douche nozzles (not to be used except upon physician's order) Two rectal nozzles, large and small One soft rubber catheter Blunt scissors for cutting cord Lysol Boric acid powder Medicine dropper Narrow tape or soft twine for tying cord Sterile absorbent cotton (preferably in 1/4 1^- packages) Silver nitrate outfits furnished by the State Department of Health free of charge. Each and every article should be inspected and opposite this list you should write "G" or "B" and "C" or " D ", for "Good" and "-Bad", "Clean" or "Dirty". 8 Note the condition of the bag, whether or not it contains a washable lining or metal case; whether it is in good or bad con- dition, clean or dirty, 9 Ascertain whether the midwife has in her possession any instruments, and inquire particularly as to the following: Speculum Dressing forceps Uterine dressing forceps Obstetrical forceps Uterine sound or applicator Hypodermic syringe Artery clamps Uterine irrigators Wire catheters Uterine syringes Any other instrument. Public Health Nursing 189 In case you have any suspicion, asik to be shown any cupboards or closets where ®uch instruments could be concealed. Ask the midwife to surrender any instrument and state that if any are found on subsequent visits you will recommend cancelling her license, 10 Note whether or not the midwife has an examining chair or table which might be used for either operations or treatments'. 11 Ascertain whether the midwife has any drugs in her posses- sion, other than the disinfectant required for her practice, and whether or not she has a medicine case or cabinet. Do not include personal household remedies or cosmetics. 12 Note whether the midwife has a sufficient supply of ophthalmia neonatorum outfits. If she has not, she should be advised that she can get them from the local health officer. The midwdfe should have in her possession a copy of Rules and Regulations for Midwives. 13 Note whether there are accommodations for the delivery of women at the midwife's home. Their presence should arouse sus- picion that the midwife might possibly be inducing abortions or labor and delivering women who desire secrecy. 14 In using the form for the inspection of midwives report as below under each heading. (a) If license sign and name are correct, mark 0. K., if incorrect, state " Inc," and notify the Albany office. (b) Note, with letters "G" or " B ", if good or bad; " C " or " D ", if clean or dirty. (c) Note '' P " or "A" for present or absent; "W" or " NW " for washable or nonwashable. (d) Inspect record of births, and if any are not recorded see that local registrar receives the report; and advise mid- wife that such an oversight is a violation of the law, and report to the Director of the Division of Vital Statistics. (e) Note number of cases attended. (f ) Note whether or not physician was called, and if so for what reason. (g) Inquire as to the general health of the midwife and her family. Also inquire whether or not there has been anj 190 State Depaetmekt of Health communicable disease in the home. Give instructions as to precautions to be taken in a case of communicable disease. (See Eules and Regulations for Midwives issued by State Department of Health.) (h) State whether wholly self-supporting or partly self- supporting and state what other work, if any. (i) Report the presence or absence of instruments. See Rule Xo. 9. (j) Report whether any additional beds are present. See Rule 13. 15. On inspection form (page 2), cheek list of equipment and note condition " G " or " B " and note instruments found, if any. 16 Each form must be made in duplicate and one sent to the Albany office and one retained by the nurse. 17 Visit each midwife during the thirty days previous to the expiration of her license and write to the Albany office whether or not you reconmiend the renewal of her license, stating why. If operating under an old license such license should be taken and mailed to the Albany office. 18 Visit the office of the local registrar and ask whether each midwife on your list is duly registered in his office as required by law. Ask also if he knows of any midwives not licensed but practicing; whether any midwife is late in filing certificates of birth, and any other information which he happens to have in regard to any individual midwife. See that unlicensed women are not registered. 19 Inquire of each midwife if she knows of any other women practicing in her neighborhood and visit any whom you think may be practicing without a license. 20 If these directions are lost or mislaid or new forms are needed apply at the Albany office. When births are discovered that are apparently or possibly unreported fill out a blank certificate of birth and have it signed by the parent, or if the parent is illiterate the parent should make his or her mark, the nurse signing as witness. The nurse should examine the register kept by the local regis- trar of vital statistics to see if the birth has been reported. If unreported she should file her certificate with the registrar. If Public Health Nursing 191 the child was born in another municipality, not visited by the nurse, the certificate should be mailed by the nurse to the registrar of the municipality in which the child was born with a statement of facts. If the nurse can not readily secure the name of the regis- trar of the other municipality, she should forward it addressed to '' Registrar of Town (or Village or City) of ". Blank certificates for birth reports are supplied by the State Department of Health to all local registrars from whom they may be secured as needed. When a nurse finds a woman practicing who apparently is unlicensed, or who can not show her license she should notify the State Department of Health giving the name and address of such woman. ]92 State Department of Healti CHAPTER XVI Health Supervision of the School Child Health feupei-vision of the school child has been the logical result of compulsory public education. The State provides the equip- ment for education and compels the child to utilize it. To assem- ble the state's children in the various school houses was the surest way to discover defects from heredity and environment in the individual. To attempt to determine clearly the nature of these defects and to correct such as were remediable was an inevitable result, necessitating for its accomplishment a more intimate rela- tion between those who control the child in school and those who are responsible for him out of school. It has long been recog- nized that certain defects increase during school years, and may be classed as occupational. Obviously the school should prevent the development of these defects. A high educational authority has said that 871/^ per cent of all education is physical. The value of the nurse's service in the community will depend on her ability to secure coi-rection of insanitary conditions in the home as well as in the school room. There has becu considerable discussion as to whether the school nurse should be assigned to the routine examination of children for physical defects and to class- room inspection to discover communicable disease. Local condi- tions, expediency and the qualifications of the individual nurse are bound to be deciding factors in most schools. No thinking person can doubt that a nurse technically well trained can discover when vision or hearing is not normal, when speech defects exist, when there is nervous disturbance, and when there are symptoms of infectious disease which call for exclusion from the classroom, and that she can properly record subsequent observations of such cases.* But the decision of which is the cause of the trouble must rest with the physician. It will often take both physician and nurse to detennine the nature and cause of an existing disturb- ance and to secure its correction. * It is also undonbti'dly true that Icaclu'ra can he so trained in normal seliools that they may Katisfaetorily pertorni siuh usual elassroom i!-speetion. Public Health Nursing 193 The interest of school authorities, teachers, parents, and the gen- eral public must frequently be enlisted before certain children will have been provided with the fundamental essentials for a healthful life and good citizenship. The provision for school instruction in the open air is one instance where community interest has had to be aroused and guided to insure to certain children a chance to live. Thus far this community interest has been largely con- lined to urban schools. To secure rural community action, to transform conditions in the one room rural school so that it will be comparable to an open air school is an urgent and vital need in the solution of which the public health nurse will have the opportunity for all the service and cooperative work of which she is capable. When the work is accomplished the children will not only be studying in the open air, but they will be warmly and suitably clothed, wisely and abundantly fed, as clean in body and clothing as soap, water and a will to be clean can make them, and they will be getting ten hours sleep out of each twenty-four. Physical Defects in the Child The following tables indicate the physical condition of school children as shown in several communities. In a recent examination of newly admitted school children in the City of New York 5,780 cases were examined by the school physicians and 5,940 by private physicians. The percentage of defects found were as follows: Examination by Examination by School Medical Private Inspectors Physicians * Defective vision 7 . 4 . Defective hearing .38 .77 Defective teeth 71.2 36.5 Defective nasal breathing 12.3 12.2 Hypertrophied tonsils 13.1 21.8 Malnutrition 6.3 12.9 Cardiac disease 1.1 2.1 Pulmonary disease .81 1.9 Orthopedic defects 1.1 1-7 Nervous diseases .91 3.9 Dr. Haven Emerson, New York State Journal of Medicine, May, 1916. 7 194 State Department of Health It is interesting to note that in ^ew York City 16 per cent of the children's parents employed a private physician. The extra expense of including these children in the medical examination by the health department physicians and nurses would have been 39 cents per capita.* An inspection of children in the rural schools of Pennsylvania in districts with population of less than 5,000 made by the Pennsylvania State Department of Health gave results as follows :f Number of children inspected 17,697 Defective teeth 53 . 7% Dirty teeth 8.4% Gums diseased 45 . 3% Tonsils enlarged 26 . 3% Adenoids 34 . 8% Enlarged cervical glands 4 . 9% Goitre 4.9% Defective vision 17 . 8% Other eye affections 3.1% Malnutrition 48 . 7% Tuberculosis 4 . 4% Head lice 27 . 5% Other skin diseases 8 . % Deformities — spinal curvature 1 . % Other deformities 9 . 3% Defective hearing 3 . 3% Defective breathing 4 . 9% Concerning the presence of multiple defects in children of rural districts and the results in treatment through advising the parent or guardian by letter, Dr. Samuel G. Dixon in the article to which reference has already been made, gives the following inter- esting figures : Total number of pupils inspected 469,199 Defective 335,427 Not defective 133,772 Single defects in 184,900 Multiple defects in 150,527 Total defects 551,671 Pupils' treatment advised by letter to parent or guardian 304,019 Pupils' reported treated ( 18% of notifications) 64,941 Pupils' improved by treatment (95% of those treated) 52.406 * Weekly Bulletin of the Department of Health, Citv of New York. June 24, 1916. t Some results of the Health Inspections of Four Hundretl Tliousand Rural School Children in Pennsylvania — Samuel G. Dixon, Commissioner of Health, Pennsylvajnia. Public Health Nursing 195 From the foregoing records the nurse is justified in concluding that: (a) approximately 50 per cent of all children on their first admission to school are in need of immediate attention for throat and mouth or eye defects; (b) a good percentage of the defects will he remedied to the improvement of the health of the child if the parent or guardian is notified in writing ; (c) in notifying the parent or guardian it is desirable to enclose literature designed to teach adults the importance of oral hygiene, and the necessity for accurate correction of defects of vision; (d) provision should be made for the correction of the defects of children whose parents do not provide the treat- ment necessary after notification; (e) the public health nurse is the best agent for accom- plishing the greatest results; (f ) when multiple defects exists, record should be made of mental, nutritional and general physical improvement fol- lowing treatment of oral and vision defects in order to fur- nish data for further study and conclusions. Methods for Securing Correction of Defects When Par- ents Do ISTot or Can Not Attend to the Matter Whenever after a reasonable time any child has not had treat- ment for the defective condition, the nurse should visit the home to urge the importance of such corrective treatment. Sometimes six and eight visits of this nature must be made before the parents sufficiently appreciate the situation to consult a private phy- sician or consent to pay for treatment when provided at cost. For children in rural districts an arrangement may some- times be made with local physicians or dentists for a day when all cases may receive operative or other treatment at cost, or with- out cost for any who should have it so provided. In some instances a date is arranged in some neighboring city and a group of chil- dren is taken to a hospital or dispensary for operation. Mobile eye and dental dispensaries are now being operated in some parts 196 State Department of Health of New York State for the benefit of rural children. Under adult stimulation the children themselves frequently organize remedial measures as valuable for educational as for corrective ends, as for example, the Nassau County Junior Ked Cross Dental Clinic. A progressive superintendent of schools in a rural village of New York State arranged to have medical and surgical service brought from a neighboring city on certain days. On these days the teachers, local nurses and citizens assisted at a com- munity session for dispensary and clinic ser\'ice. In the library of the school cots w^ere placed, while the superintendent's office was the (jperating room, the school nurse managing the nursing side of the function. The domestic science class washed the towels and helped in the general clean-up. With a little enter- prise and enthusiasm this community work may be developed in any rural district. A well written newspaper account of how it was done inspires other neighborhoods. The two factors which the nurse will find necessary for the accomplishment of this corrective work are the recognition that it is needed and the development of a desire on the part of the people to provide it. The cost of the work under such community initia- tive will be reduced to a minimum, and will come within the means of a large proportion of both native and foreign born parents. The nurse should know the number and the nature of her cases, and she should find out the comparative cost in time and money of taking the children to another place, and of bring- ing the treatment to the children. The preferences of local phy- sicians and dentists should be considered before any decision is reached. Some Eesults to Health From the Continued Presence of Physical Defects From Decaying Teeth and Diseased Gmns and Tonsils Oral sepsis as a factor in general systemic disturbance has for some time been generally recognized. That decaying teeth — even those of the temporary set — may result in disease of the tonsils, middle ear, and glands of the neck has been long recog- nized; more recent is the knowledge that arthritis, endocarditis, deafness, functional heart disturbance, mastoid disease, asthma. Public Health ISTuksing 197 goitre, frequent sore throat, neuritis, appendicitis and cholecystitis often are caused by a septic focus in one or more teeth, or from diseased tonsils. Insanitary fillings, insanitary crowns and other forms' of dentistry have resulted in as much general dis- turbance as have totally neglected teeth. Diseased tonsils and dental caries may produce conditions favorable for infection with communicable disease, including tuberculosis. Adenoids and eye defects are the cause of much backwardness in mental development, of faulty posture and of general nutritional disturbance. Deafness, anemia, nutritional disturbances, mental sluggish- ness, glandular swelling and spinal curvature are frequently fairly easily corrected when hygienic care of the oral and buccal cavities is established. Nervous disorders in children may have their origin in some of the above named defects. The nurse can not place too much emphasis on the value of their prompt cor- rection. " One result of five years' work (in mouth hygiene work at Bridgeport, Conn.) is an average reduction of 33.9 per cent in the number of cavities in the permanent teeth of the fifth grade cliildren . . . No repair work had been provided for these childreii; the work consisted of prophylactic treatments, toothbrush drills, and instruction in mouth hygiene." (See 1919 Report of the U. S. Commissioner of Education.) 8ore Eyes amd Blind^iess If in her visits to the home any child under two weeks of age is found with sore eyes, the nurse is required by Section 288, paragraphs 3 and 4 of the Penal Code to report the fact immedi- ately to the local health officer or to a local qualified practitioner of medicine. Failure to comply with this law, or for the nurse to undertake to treat the case without medical advice is a mis- demeanor. The penalty for a misdemeanor is a fine of not more than two hundred dollars or imprisonment of not more than six months or both. Regulation 6, Chapter II of the Sanitary Code requires that a visiting or public health nurse report at once to the local health officer any case of disease presumably com- municable. These two laws, therefore, make it mandatory that 198 State Department of Health all cases of inflamed or sore eyes in infants shall be reported at once by the nurse to the local health officer. Many nurses do not know this fact. A smear of the discharge may be made and sent to the State Laboratory at Albany to facilitate diagnosis. If any person is found blind or in danger of blindness and not under medical care the nurse should inform the New York State Commission for the Blind. The Commission will promptly insti- tute measures for prevention or relief. The Eyes and Ears of School Children * "The State Medical Inspection Law (Laws of 1913, chapter 627) provides that medical inspectors or principals and teachers in charge of public schools shall make eye and ear tests of the pupils in such schools at least once in each school year, and that the school authorities shall be furnished with ' suitable mles of instruction as to tests and examinations' so made, together with test cards, blanks, record books and other useful appliances for carrying out the purposes of this article. In compliance with this law, the State Commissioner of Educa- tion prescribes the following: "Instructions to Teachers, for Examination of the Eyes and Ears of School Children 1 The aim of the school tests. The mere examination of eyes and ears and recording of statistics are of no value to the children. Unless their defects of vision and hearing and any other eye and ear troubles that are discoverable by the teacher are brought to the attention of parents and guardians, the examination will fail of its purpose. But this is not all. A child is not relieved by merely telling his parent or guardian that he has a remediable trouble of the eye or ear. The case must be taken to a competent eye or ear specialist who should report to the school on the blank provided for this purpose. * Copy of circular issued by the New York State Department of Rlucation. Public Health ISTuksing 109 " This should always be done through the activity of the family physician who either attends the case himself or refers it to an expert on eye or ear conditions, " One of the objects of the medical inspection law is to prevent every possible case of preventable disease from developing among school children and to apply the right remedies to every case of disease or defect that can be cured or relieved while in school. The law gives the teacher a large share of responsibility in attain- ing this object. " 2 Time of the tests. These tests should be made as soon as possible after the beginning of the school year in order that the defects thus discovered may receive early attention. Pupils enter- ing school after the regular tests have been made should be tested as promptly as possible. The date of the test should be entered on every pupil's record. " 3 Conditiom of tests. Tests should be made under uni- form conditions, as nearly as possible, and these conditions should be the most favorable that can be attained. Tests of vision should be made in the forenoon, if convenient, and never after 3 p. m. If the day appointed should happen to be cloudy or dark it would be necessary to postpone the tests, unless proper artificial light were available. "Children should always be examined singly and should be screened from the sight of the rest of the class. If possible, a separate room should be used for these tests. " 4 Persoiml liMory of pupil. The following facts should be recorded for each pupil, regardless of age: a ]^ame h School and grade c Date d Age (date of birth) e What serious illnesses have you ever had ? (date if possible) / Do you have headaches? How often, how severe, and in what part of the head? Are they afternoon headaches? Worse after using the eyes ? Absent on Saturday or Sun- day ? g Do you have pain in the eyes? 200 State Department of Health Ih Do you have dizziness or nausea? (Are you ^ sick at the stomach? ') i Do you have trouble in reading the book or blackboard ? j Do you often ' see double ? ' h Do you have earache ? How often and how severe ? I Did you ever have running ears? (date if possible) m Do you breathe through your nose easily ? II Do you think you can hear as well as other children ? Do you have frequent colds in the head, with discharge from the nose and throat ? " Young children do not give reliable answers to the above ques- tions. The teacher should, if possible, secure the desired informa- tion from parents or older brothers and sisters. When a child's history is unfavorable in respect to the points just mentioned, his parents should secure competent medical advice for him, without regard to the results of the eye and ear tests described below. The physician to whom the case is referred should report to the school on the blank provided for this purpose. " 5 Observation by teacher or nurse. The teacher will often be able to answer some of the questions on the above list. She should also record the results of her observations of each pupil under the following heads, not depending on the child's' state- ments alone: a Are the child's eyes straight ? Is he cross-eyed or ' wall- eyed ? ' h Does he squint or frown habitually ? c Can he read from the blackboard as readily as other pupils ? d Does he hold his book 12 to 14 inches from the eyes? e Does his pos-ture while reading indicate any difficulty in see- ing distinctly? / Is he easily fatigued, and does the use of his eyes appear to increase fatigue ? g Are the eyes healthy in color and appearance? h Are the eyelids healthy in color and appearance? i Does it seem that the child's eyes are oversensitive to light? j Does he seem to hear easily at ordinary distances ? Public Health Nursing 201 h Does his posture or attitude indicate any difficulty in hear- ing? I Does he often say " What ?" when asked a question, or ask you to repeat the question ? m Is he usually attentive and interested in what others are say- ing? n Do the ears look healthy ? Are the ears obstructed by wax ? " The above items constitute a personal history of the child and are of great significance in deciding whether the child shall be sent to a doctor for further examination and diagnosis. Doubt- ful or unfavorable answers to any of these questions would war- rant the teacher in warning the parents concerning the child's eyes or ears, " Defects of vision and hearing are often insidious in their ori- gin and development. For this reason, children in school should he observed closely in order to detect the first indications of failing sight or hearing. When defects are found or even suspected, the child should have the advantage of expert examination and treat- ment without any hesitation or unnecessary delay. Above all things', the school authorities, m.cdical inspector and nurse should make the required examinations and tests with a full knowledge of their significance. " 6 Preparation for tests of vision; apparatus, etc. The teacher should secure the information called for above before beginning the tests of vision and hearing. She should then study the fol- lowing directions most carefully and see that all preparations have been completed. " The tests of vision are made by using a Shiellen's Test Card containing letters and ' inverted E's ' adapted to the vision of the normal eye at distances of 200, 100, 70, 50, 40, 30 and 20 feet respectively. The Snellen card can be obtained from local op- ticians, printers of school blanks, etc. The card should be kept well protected from light and dust and should never he exhibited to the pupils except during the test of vision as children readily memorize the letters. The card should be hung with the 20-foot line on a level with 202 State Department of Health the child's eyes. It should be well illuminated and should not re- flect a strong light into the eyes of the child. It should be out of sight of the class. The child should sit directly in front of the card at a distance of exactly 20 feet between the eyes and the card. There should be no cross lights or reflections from windows or blackboards to dazzle the child during the test. While conducting the test the teacher should stand near the test card. If it seems desirable she may point to the letters, using an ordinary ' pointer.' She must not interfere with the illumi- nation of the card, nor obstruct the children's view. "7 Tests of vision — to he applied to children 7 years of age or older, a Children having glasses should be tested with their glasses properly adjusted to their faces. If necessary they should be sent to an expert for a fitting before the test is made. They should then be tested without their glasses and the results of the two tests should be carefully compared to ascertain the degree of relief afforded by the glasses. " b Children who are under the care of physicians must have these tests made and recorded the same as those who have no regular medical care. " c Seat the children 20 feet in front of the Snellen chart. See that the chart is well illuminated, as described in section 6, and that the child's eyes are on a level with the 20-foot line. " Instruct the child to cover the left eye w4th clean screen (heavy cardboard is good) held against the nose. Do not allow the child to cover the eye with the hand or make any pressure whatever on the eyeball, as it will interfere with the test of the left eye later on. "Ask the child to read the letters aloud, in regular order, begin- ning with the top line. Make a note of the smallest line that he reads with no more than three errors in naming the letters. " In the same manner ask the child to cover the right eye and name the letters from the top line to the bottom, in the reverse order — from right to left. This is done to prevent the child yc~ peating the letters from memory, ISTotes the smallest line tliat lie reads with the left eye, with three errors or less. " d Use of ' inverted E's.' For the child who does not know all the letters, ' inverted E's ' are included in eveiy line of the Public Health Nursing 203 card. The child should be instructed to indicate by his extended fingers the position of the E as pointed out by the examiner. In other words, the child holds his open hand with the fingers point- ing up, down, right or left, as in the character pointed out. " It is well to have a large letter E cut from cardboard or sheet metal which the child can hold to represent the position of the letter pointed out by the teacher. Note the lowest line in which he sees the E's with not more than three errors. " e Memorizing. If it is suspected that the answers are being made from memory a hole about one and one-half inches square may be cut in a strip of cardboard so as to allow only one or two letters to show through the hole, rnd by skipping around rapidly it is easy to break up the memorizing of the letters. This method may be of use also in testing little children. (See 7 /.) '"'' / Eecord of distant vision. The letters of Snellen's Test Type are standardized for certain distances from the normal eyes. Thus, the letters marked 100 are readily distinguishable by the noi-mal eye at a distance of 100 feet; those marked 40, 30, 20, etc., are each distinguished normally at the corresponding number of feet from the observer. " The child's visual power is rated by a fraction, of which the numerator is his distance from the test letters — in this case 20 feet. The denominator of the fraction is the number belonging to the smallest line of letters that he reads without more than three errors. If he reads the 20-foot line passably with the right eye his vision is recorded as R 20/20. If he fails on the 20-foot and 30-foot lines and reads the 40-foot line his vision is R 20/40. " When the child fails on all the lines he should go nearer the chart, say 10 feet, and try the test as before. The numerator of his fraction will then be 10, and he may be rated as R 10/100 or R 10/70, etc. When the child takes a position nearer than 20 feet, he should be tested on several lines, and not on the same line only, with each change of position. " Be sure to measure carefully the child's distance from the chart. " Pacing " the distance or estimating it in any other way is absolutely inexcusable, because liable to be very inaccurate. " Remember that if the vision of one eye is poorer than that of the other eye, it may be due to pressure on the eye from the hand 204- State Department of Health that covers it. Do not allow either eye to be pressed upon while the other is being tested ! '' When a child reads the letters correctly, but very slowly, or with much hesitation the fact should be noted by the teacher, and an explanation should be found if possible. The teacher should also observe and record the child's posture and general attitude. The position of the head, and the expression of the face may be positive evidence of eyestrain. " Little children often transpose the letters in reading This is a pecularity of child psychology and has notliing to do with the rating of the vision. The use of the cardboard aperture, described in 7 e, will prevent transposition. " 8 Notification of parents and guardians. When the visual power is 20/30 or less, for one eye or both, the child should be re- ferred to a specialist for further diagnosis and advice. The same course should be followed if the child's condition suggests eye- strain or eye disease. " If a child wearing glasses fails to do well with the tests of vision, or if his glasses do not seem fully to relieve his disability he should be referred to a specialist, who should certify that the child has received the necessary attention. " Testing of hearing — for children of all ages. " a Directions for testing. The room in which these tests are given should be not less than 25 or 30 feet long and as quiet as any that can be found. The windows and doors should be closed. The floor should be ruled with parallel lines one foot apart and the child should sit in a revolving chair on the first line. No other pupils should be in the room during the test. The examiner should be a person of normal hearing, as determined by the test, and should stand at a measured distance of 20 feet from the child. There should be nothing back of the examiner that could act as a sounding board — such as a door or a vibrating wall. " I^ofore making these tests the examiner should ascertain, by practice with persons of normal hearing, how to regulate the whispered or low-spoken voice so that it will be heard plainly at a distance of not more than 25 feet, "The child shcmhl ])C instructed to tuni the right ear towards the examiner, and to i>hu'e the finder in the left ear firmly enouffli Public Health Nursing- 205 to prevent hearing. He should be told to listen attentively, with his eyes closed and to repeat the numbers that the examiner whispers to him. " The examiner then pronounces a number of two or more sylla- bles, such as " fifty-four," in a whispered or low-spoken voice of moderate intensity. The child will repeat correctly three out of five such numbers if his hearing is normal. If not, the examiner moves a foot or two nearer and pronounces another series of five numbers, keeping up this procedure until the child hears dis- tinctly three or more of tlie five numbers. The examiner notes the distance at which the right ear hears distinctly, and then tests the left ear in the same manner. " It is important not to correct the child's responses to the test but to proceed as though all the lesults were favorable. The ex- aminer should also aim to maintain the same quality and volume of voice throughout the tests and to pronounce the syllables with equal emphasis, speaking deliberately and distinctly. For this reason it is best that the same examiner should test the entire school in order that the results may be impartial. " h Record of hearing tests. The record is made in the form of a fraction, having for its denominator the distance at which the whisper is audible by the normal ear, that is 20 feet, and for the numerator the actual distance at which the child hears well. If the child's right ear hears nonnally, or at 20' feet, his record is R 20/20. If with his left ear he hears the test words at a dis- tance of only 8 feet his record is L 8/20. '' c Alternative riiethods. A child who is too young, careless or inattentive to respond fairly to the whispered numbers may be placed with his back to the examiner at a distance of 20 feet and told to close one ear as in the preceding directions. The examiner then whispers an order such as : ' Hold up your right hand,' or ' Open the door.' The greatest distance at which the whispered order is carried out is used as numerator of the hearing record for the ear undergoing the test. '' d Form of permmient record. The school blank form is designed to record the results of the hearing tests. '' Notification and foUow^ip luorh. Any impairment of the hearing, however slight, is a serious menace to the future well- 206 State Department of Health being of the child. Deafness is often of slow and gradual de- velopment and the merest suspicion of its onset ought to be the signal for expert medical examination and treatment. For these reasons the teacher is' urged to notify the parent or guardian when the child does not give a satisfactory response to the tests for hearing. Any unsatisfactory answers to the questions in sections 4 and 5 should also be regarded as sufficient ground for asking parents or guardians to seek medical counsel for the child in order to prevent more serious ear trouble in the future, "Importance of proinpt relief of defects of eyes and ears. The child's eye, like the rest of his body, lacks the strength and endurance of the adult's. The child's eye is readily deformed and drawn out of shape by a stress or strain that would easily l>e endured by the adult's. Every physician learns from observation that the eye troubles of a child are likely to grow worse unless the eyes are properly relieved by making their work easier or by the use of glasses. " ' Squint eye,' ' cross-eyes,' or strabismus, if beginning early may progress until, at the age of 10 years, unequal traction on the delicate eye muscles has changed a pretty face into a pathetic cari- cature and greatly reduced the visual power. " ' Near-sighted ' or myopic eyes tend to become worse instead of better, and by constant distortion of the eyeballs may end in partial blindness. " It is a costly mistake to assume that the school child will ' out- grow' any defect of vision. The truth is that defects usually grow more numerous and more serious as the child grows older. Eyestrain is likely to develop near-sightedness and this leads to impairment of vision. ' Cross-eyed ' children grow into ' cross- eyed' men and women and often suffer from the weakening of one or both eyes. Inflammatory disease? of the eyes, as a rule, tend to become chronic or more disabling unless promptly treated. " Every school child with signs of any of these defects, and every child annoyed by dizziness, nervousness, headaches, ' seeing double,' styes or other troubles traceable to eyestrain should have the services of an expert in diagnosis and treatment of eye dis- orders; and under no conditions should the examination and treat- ment of the eyes be postponed until ' a more convenient season.' Public Health E'ursing 207 " It is equally important to attend promptly to every child whose hearing is impared. Defects of hearing are liable to grow more serious with age. The child hears less and less of what is going on around him and profits less from the school and from human intercourse in general. There is no other physical defect that retards the child's progress in school so hopelessly as defective hearing, without adequate relief. " Every case of suspected adenoids or enlarged tonsils and every case of mouth breathing should have prompt examination and treatment by a competent physician. Neglect of these con- ditions may lead to the development of serious complications in the ear, the mastoid cells and other adjacent structures. Frequently recurring nasal catarrh also should have thorough treatment because it is liable to extend from the no,se through the connecting channels to the middle ear, where it may cause abscess or chronic inflammatory disease, and deafness. " Excessive accumulations of wax in the ear may cause distress or deafness. Although it may seem easy to remove wax from the ear, this" should not be attempted by an inexperienced person as serious damage might be done to the ear drum." Education of the Blind Child All blind persons of suitable age and capacity for instruction who are legal residents of the State of New York are entitled to education without charge in the State School For the Blind. The application for admission should be made to the board of trustees of the State School. Paragraph 993 of the Education Law directs that the application be accompanied by a certificate from the county judge or county clerk or the supervisor or clerk of the town or the mayor of the city where the child resides " setting forth that the applicant is a legal resident of the town, county and state claimed as his residence." The Deaf Child If a deaf mute under the age of 12 years becomes or is in danger of becoming a public charge the public health nurse should apply to the local overseer of the poor or commissioner 208 State Department of Health of charity or to the to^^^l supervisor, or if in a city to the ward supervisor to have the child placed in a state institution for education. The law is mandatory that all such children shall upon application be provided for. Their maintenance is a charge upon the county. The State Board of Charities should also be informed of the case. Orthopedic Defects These defects are probably much more prevalent than is gen- erally believed. Miss Jessie Bancroft, Assistant Director of 'Phy- sical Training in the public schools of New York City estimates that " probably 80 per cent of so-called normal children have antero-posterior faults of posture." She also estimates " that 85 per cent of the time spent in school calls necessarily for positions, the influence of which is toward poor posture, that the balance of 15 per cent is vitiated in its possible influence by poor furniture, poor light, fatigue, physical defects, etc., and that only 11 per cent of the time (physical training and singing) makes actively for good posture." * Dr. Lloyd T. Brown in the examination of 700 school children in the Boston public schools found three-fourths of the children in bad posture, one-third of the boys and three-fifths of the girls had faulty weight bearing foot posture. The tendency to bad posture increased as the children advanced to higher grades, while in the high school " bad posture was nearly twice as common the body has a definite relation to faulty use of the feet. This should be a very important point in the care and hygiene of our school children." f J Dr. Hills Cole at the Fourth International Congress on School Hygiene said: "We must conclude that foot strain in school children is more common than eye strain, and its effects are just as serious. It is caused by the muscular effort involved in • Report of Traiisactior.e of Fourth International Congress on School Hvffiene, Vol. IV t Report of Transactions of Fourth International Congress on School Hygiene, Vol. V. t Weak Ankles, Flat Foot, Spinal Curvature in School Children, by Hills Cole, M. D., Monthly Bulletin of State Department of Health, October, 1913. Public Health Nursing 209 balancing the weight of the body in a shoe, the bottom of which is smaller than the bottom of the foot. If the foundation of a school building did not come out as far as the side walls the pupils would be constantly menaced by the liability of the structure to collapse. A weak ankle or flat foot is a foot that has rolled inward over the shoe bottom because the strain on the muscles whose function it is to hold up the inner arched border of the foot has caused them to lose their grip and to let the weight of the body rotate the foot inward and downward. " Foot strain is also a matter of vital moment to the school teacher. " If the foot rolls inward under the body weight unnatural pressure is brought on the side of the great toe joint, and a ' bunion ' is produced. " If the toes are cramped in shoes, the muscles of the foot can not act freely and strain is put upon the other muscles in the effort of walking. " If the shoes are made on a twisted last, walking is more of an effort than it should be. High-heeled shoes throw undue weight on the ball of the foot, and at the same time make the foundation upon which the weight of the body has to be borne less secure; each defect involves muscle strain in the endeavor to minimize its effects. " Eolling of the foot interferes with the circulation in the foot and leads to swelling, which fills up the hollow of the arch and adds to the appearance of flatness. " In addition to these primary effects, we have secondarily a natural diminution of the general efficiency of the sufferer from foot strain. If the feet are demanding more than their share of the body's output of nerve force or vital energy, some other part, or the body as a whole, must get less than its share. If there is any foot suffering for the mind to dwell upon, the pupil or teacher, as the case may be, must give less attention to the. lessons ; and the demands of the modern school curriculum are surely exacting enough to call for all the vital energy pupil or teacher " For the prevention of or relief from weak ankles or flat foot, a shoe must be worn in which the body weight is properly dia- 210 State Department of Health tributed, and with a bottom so planned that the foot has no tendency to roll o\'er it. It is not sufficient to give plenty of room for the toes; it should be a straight shoe to conform to the natural axis of the foot ; a firm sole gives stability to the founda- tion without necessarily interfering with muscle action; but above all, the rear half of the shoe must be right as this is the most important part since it receives the body weight ; the shani between the sole and heel should be short and wide and so placed on the shoe as to meet all the lines of weight thrust, forward and lateral extension of the heel being employed for this purpose. " Too much care can not be given to the correct shoeing of chil- dren, not only for the sake of conserving the health and happiness of the child, but also with an eye to the future that there may be no crippling of the feet in any degree to act as a bar to progress dur- ing the later productive years of life. "As to the spinal curvatures dependent upon foot weakness, if pronation, of the foot is prevented by a shoe constructed along the lines indicated, the curvature will gradually correct itself. \Vlien the foundation is scientifically constructed, the superstructure is plumb." Many parents belie^^e their children will with increasing years outgrow these childhood defects, and therefore neglect to care for them. Instead of outgrowing them only too frequently the result is a general systemic disturbance which still further incapacitates the child in the general competition for a place among his fellows. Since faulty posture and spinal defonnity are frequently caused by general muscular weakness due to faulty nutrition or unhy- gienic home conditions, the nurse will need not only to strive to prevent the development of these defects but to participate in the work of securing their correction. To accomplish this the dietary of the child will require her attention. Malnutrition To correct faulty nutrition of the child frequently involves changing the food habits of the entire family. Many of the children may be taught good habits through nutrition classes in the school ; for others intensive home work will be needed before Public Health Nursing 211 progress will be made. Sometimes the mother will need to be induced to change the disposition of the entire family income before the diet will be adapted to the needs of the different mem- bers of the household. This may sometimes be accomplished through neighborhood classes; sometimes it calls for individual instruction in the home, and a good knowledge of budget making. It will be necessary to consider what the local market offers, and what the family income is. A good deal of enthusiastic com- petition may be developed among the mothers or possibly the older girls of the family in preparing desirable dishes or bringing the children up to the standard. It is important that the nurse should understand that nutrition is intimately involved with other matters of personal health, such as good teeth, vision, hearing, posture, and even with mentality, and that with nutritional im- ])rovement she may look to find other defects tending toward cor- rection. Much good literature is available for guidance in this field, and the New York State Department of Education has special instnictors who are supervising the development oi methods in all public schools of the State. Parent-Teacher Asso- ciations will frequently take over the ways and means of securing funds for demonstration. The Junior Ked Cross is an invaluable ally in helping to " get things across," particularly the things which make for healthier boyhood and girlhood. Any child 10 per cent or more underweight should be placed in the nutrition class. After-Care of Infantile Paralysis In addition to the minor orthopedic defects cited in the pre- ceding section, there are found in nearly every community of the state children and adults who are seriously lame or deformed, and who are going about with a twisted contorted gait or with the aid of crutches, or who may even be confined to a wheel chair. The majority of these cases have resulted from the effects of poliomyelitis (infantile paralysis) where there has been no treat- ment or the treatment was inefficient or not continued sufficiently long. A few of the cases are beyond all help, but the majority can be greatly benefited by hospital care, operations and proper apparatus and can thus be restored to school life or enabled to 212 State Department of Health earn a partial or comjjlete livelihood. The State Department of Health employs an orthopedic surgeon and a staff of specially trained nurses, each in cha;rge of a district, who are at the ser- vice of any community free of charge. Should a nurse discover any cases of infantile paralysis or after effects of that disease, which are not receiving medical or surgical attention, she should report to the local health officer or school inspector, or directly to the State Department of Health, and the services of the orthopedic surgeon and the state nurse will be promptly given. K"urses not specially trained in the management of such cases should not undertake their supervision until they have received instructions in each case from experts. " Suggested Duties of the School Xuese * " 1 To assist the medical inspector or teacher in examining children and in keeping records. 2 To visit the homes of those needing treatment and to urge its necessity on the parents. 3 To watch for any evidence of contagious diseases or con- ditions in the school, and when found to notify superintendent, principal, teacher, or medical inspector. 4 To detect and refer to the family physician, medical inspector or dentist any evidence of eye, ear, nose, or throat trouble or other physical or mental defects. 5 To render first aid in emergency cases occurring in schools and to see that child is taken either to its home or to the family physician. 6 To report to the superintendent of schools or principal any error she may detect as to light, heat, and ventilation in the schools', or any improper seating or other insanitary conditions. 7 To follow up absentees occasioned by medical inspection, or where contagious diseases or conditions may be suspected. 8 To follow up recommendations of family physicians, dentist. or medical inspector, and to inform the superintendent of schools or principal of results obtained. 9 To accompany children in special cases with written per- mission of parent or guardian, to hospital, dispensary, family * Prepared by the State Medical Inspector of Schools. Public Health Nursing 213 physician, oculist, or dentist, and to secure from such a report as to services rendered to pupils. 10 To investigate and improve home conditions where neces- sary by instructing children and parents in matters of personal and home hygiene and to bring home and school closer together. 11 To investigate reasons for truancy and to do whatever may be possible to remove home causes. 12 To keep employers and parents informed regarding child labor, compulsoiy attendance, medical inspection, vaccination and other laws bearing upon the health of the school child. 13 To cooperate with physicians, dentists, school authorities and others in better conserving the health of the child and improv- ing its environment, both at home and at school. 14 To perform such other duties as may from time to time be prescribed by the board of education or by the medical inspector." Physical Educatio'jst The jSTew York State law making physical education compul- sory for all pupils, male and female, eight years of age and over in public, private and parochial schools was enacted in 1916. An average of at least twenty minutes a day throughout the school year is required for the subject. The result of this has been the development of a syllabus in physical education which has for its objective the offering of such stimulation to the potential capacity in the child for muscular activity as will " contribute to the development of bodily vigor and endurance, muscular strength and skill, bodily and mental poise, and the social and moral qualities of courage, self-control, self-subordination, cooperation under leadership and disciplined initiative." Drills, games, sports, athletics, romps and gambols have become a coordi- nate part of school activities, among which exercises specially designed to correct existing physical defects have been introduced as their need has been indicated. This introduction of a physical education program as a com- ponent part of general education is having a far reaching effect upon training for citizenship. ITowhere is this more apparent than among industrial and commercial forces. A posi- tive appeal has been made to be permitted to be bom fit and 214 State Department of Health to remain fit, to know the joys of life of the free-born and to spread the contagion of happiness that grows through successful endeavor. The response to that appeal has been to motivate health conservation. Rural people, always at first somewhat conservative to new doctrines, are gradually responding to the appeal. The big factor in so presenting the subject that it will secure immediate and hearthy response is the application of the principles of psycholog}^ to the teaching of health conservation. The vital j)rinciple governing the method is to make the subject look so attractive that children will be so eager to possess it that they will nin after it and be willing to even make personal sacrifice to have it for their own enjoyment. It is practically identical with business methods in salesmanship involving good advertising. By this method passive receptivity is transformed into personal initiative, enthusiasm is aroused, teams are organ- ized for contest and competitioji; in short, health conseiwation becomes good sport. It was the physical inaction of former methods of teaching hygiene which made it so irksome; learning from books is dull business for children until they want some definite information and are directed to a book where they can find the thing they are looking for to ap})ly to some situation in which they are interested. This sort of presentation of the subject requires good teachers; the demand for this type of teacher has exceeded the supply and is increasing. To get the cormnunity's children critically to look over themselves, their homes, and their neighborhoods and to score themselves and each other according to a scale upon the merits of which they have previously passed judgment, to have them score their wells, privies, bams, and other in(lis[)ensable ivquire- ments and compare results with each other, to have them take up the matter of making a higher score on any matter from under- weight or dirty teeth to a better system of lighting, heating and ventilating the school house calls for leadership in which teacbers admit they receive from their pupils as much as they give. This frank comradeship in action is what makes this sort of teaching a success, be the pupils children or adults. Dead methods of teaching health subjects are being discarded as rapidly as teachers can be trained in the better wav. It is not too much Public Health N'urshstg 215 to hope that with this new broad avenue opened in public health education not only teachers of physical education, but all students of public health, will be instracted in the psychologic method of approach, or as some prefer to call it, this art of advertising and selling health. The general plan for physical education for schools in the State as adopted by the State Department of Education is as follows : '•First: (1) Individual health examination and personal health instruction (medical inspection) ; (2) Instruction concerning the care of the body and con- cerning the important facts of hygiene (recitations in hygiene) ; (3) Physical exercise as a health habit, including gymna- sium, elementary marching, and organized, super- vised play, recreation and athletics. " Second: (1) That the class teacher assist in the individual health examination and personal health instruction of pupils through (a) Rapid inspection of all pupils at the beginning of each day's session; (b) Reference to the proper authority of all chil- dren showing need of personal examination and advice; (c) Appropriate exercise and recreational pro- vision for all pupils reported by the medical inspection as organically unfitted for regu- lar physical exercise ; (d) The following up of all health advice that can be followed up. This assistance from the regular class teacher is not to take the place of the work of the medical inspector or school nurse. "Third: (1) That class instruction concerning the care of the body and the important facts facts of hygiene be given by the class teacher, except in schools in which special teachers are appointed ; 216 State Department of Health '' (2) That the syllabus on physiology include such sub- jects as the following: (a) General — 1 Hygiene of the teacher 2 Sanitation of the school room and playground 3 Hygiene of the janitor 4 The use of pupils as 'health officers' or ' sanitary inspectors ' (b) Syllabus for elementary grades, the general topics being cleanliness, position, cheer- fulness, care of the skin, care of digestion, care of the muscles, care of the eyes, care of the ears, nose, and throat, care of the teeth, care of the heart and circulation, care of the lungs, care of the nervous system. "Fourth: (1) That the instruction in physical exercise include practice in such activities as gymnastics, march- ing, play, recreational exercise, and athletics, and that reasonable and approximately equivalent activities in the home or community life of the child be accepted as substitutes of this require- ment." (The syllabus for Physical Training may be had on application to the State Department of Education.) Physical Education in Part-time Schools The recently enacted law creating part-time schools in commu- nities of 5,000 inhabitants or over, to be administered by local boards of education, will insure to all boys and girls between the ages of 14 and 18 years who have discontinued attendance for full-time instruction, a continuation of this invigorating influence. This new law creating part-time schools with state and federal aid is carrying physical education into the heart of agricultural and industrial communities. The administration of the law assures cooperation between agricultural and industrial interests, pros- Public BQealth ISTursing 217 pective workers and local education forces in the 103 dis- tricts in wliich the law will become operative in the autunin of 1920. The annual requirement is not less than four and not more than eight hours weekly during 36 weeks of each year, the sessions to be held on regular school days between the hours of 8 A. M. and 5 p. m. It is intended that not less than one- eighth of the time shall be given to physical education and hygiene. The type of schools to be established under this law includes gen- eral industrial schools, unit-trade schools, schools of agriculture and schools in practical arts and home-making. To these are added evening schools for male or female pupils over 16 years of age which " shall provide instruction in subjects related to the practical work carried on in such employment." All persons, firms or corporations employing minors between 14 and 18 years of age are required to permit such children to attend these schools. Recent surveys made by the Division of Agricultural and Indus- trial Education indicate that manufacturers are ready to partici- pate to the fullest extent in making this work fit the community need. Salesmanship Methods fok Health In actual practice it has been found that the same form of health education which appeals to children, viz., health as a by-product of games, sports and athletics, is the one which appeals to their elders. A group of Austrians in a central 'New York village watched the physical director of the gymnasium of the industry employing such methods as he coached fellow-workmen at baseball. Upon his invitation to them to come and take part in a game they seemed a bit confused, but tried the game, changed their efforts to something else, finally developed an interest in basket ball and made up a team of Austrians. They spoke practi- cally no English at first, but learned to use a little English while learning the game. One evening after play they proposed to the director that he should go to their homes evenings and teach them how to speak and read English " like Americans read." The director accepted the invitation and the first Americanization class in that part of the state was begun as a by-product of the gymna- sium. In the same way good health habits regarding food have been taught in the cafeteria of an industry. " Taste this pudding 218 State Department of Health before you swallow it ; if you like it keep tasting before swallow ing ; we will make things that you like to taste before swallowing ' if you will tell us what they ai-e " printed on a card and served with a pudding produces a more satisfactory reaction than an appeal not to bolt the food. By such methods health habits are being established among working people. The cafeteria creates a demand for good food; the athletic program establishes habits which eliminate the waste products; the clubs train in citizenship and self-government ; the factory personnel enjoys life and spreads the contagion of happiness resulting from good habits. No negative appeal through fear of malnutrition, pasty faces and defective bodies would ever get the hearing which this sort of appeal secures. A country physician near Lake Ontario found a neighbor's motherless daughter, a girl of 16 years, with tuberculosis. He set about stimulating in her a longing for a Ford runabout and then induced her father to buy it for her, saying nothing to either of them about her disease as her mother and only brother had died of it. The girl in her runabout soon became the most familiar object in that countryside. Before summer came roses were in her cheeks, she had taken on weight, and a year after the former exam- ination the physician could detect none of the previous dreaded symptoms. CooPERiiTioN IN Physical Education and Health Supervision The response of the public to this development of health through play activities, and the fact that '' the 50,000 teachers in the pub- lic schools are every one expected to take some part in physical education," has led to special courses in health work for normal school students. If health for everybody could be captured with a butterfly net, the situation would be simplified. But the fact still remains that not all children are physically fit for even nonnal play activities. For this reason the school medical inspection must take place before physical training begins. Teachers are expected at all times to refer to the medical authority all children who appear to present a departure from the normal. The medical inspector is expected " to establish the limitations within which such child may exercise." Corrective exercises are developed to meet individual needs. Public Health Nursing 219 CHAPTER XVII Mental Hygiene In general little time or opportunity has been given in the training of nurses for instruction and supervision in mental hygiene. Few hospitals provide, even temporarily, for those who are mentally ill. Most hospitals provide only medical, surgical and obstetrical care for acute or subacute cases. The tuberculous, too often considered hopeless, have been frequently permitted to die without care. The feel)le-minded, epileptic and insane have been hidden in many instances from public notice, and in the last extremity have been confined in the almshouse or jail. The reason for this has doubtless been the lack of beds and facilities and because while speedy visible results follow medical, surgical and obstetric care, results from the treatment of tuberculous and mental instability require many weeks or months. The public is beginning to understand that tendencies to theft, arson and mur- der may be recognized early, the thoughts of these persons diverted into other and normal channels and crime be prevented. Perhaps less generally understood is the fact that much insanity may be prevented if school medical inspectors, health officers and public nurses are familiar with the early symptoms indicating mental instability, and if cases with predisposition to psychosis and psychoneurosis be given suitable early training and treat- ment. To the public health nurse, whether serving a board of health, a board of education, or however employed, will often fall the duty and opportunity to prevent disaster to the individual and society by securing early clinic treatment for this class of cases. Unfortunate heredity, abnormal surroundings in child- hood, intoxication by alcohol and other poisons during the for- mative age, are predisposing causes of mental disorder. Dr. William Bumham * of Clark University has named as characteristics of the sane nmid the following: 1 Ability to give attention to the present situation ; 2 Orderly association of ideas ; • Transactions of the Fifteenth International Congress on Hygiene and Demography. 220 State Department of Health 3 Normal reaction to feeling and emotion (a) first physical, (b) secondary associated psychic; 4 Inclination to proper alternation of periods of work and rest; Conversely the following symptoms are characteristic of dis- ordered mentality: 1 Inability to attend to a present situation; 2 Inability to associate ideas; 3 Failure in appropriate feeling or emotion, reaction, or in psychic adjustment controlling physical reaction; 4 Absence of disposition to alternate periods of effort and relaxation. Dr. Franlilin E. Williams * of the Massachusetts Society for Mental Hygiene calls attention to two types of personality which are found frequently among those who develop insanity of adole- scence and which may be recognized during the school period : (a) the precocious restless type, feverishly pursuing knowledge and the accumulation of facts which they gather but fail to utilize; (b) the reticent unsocial type, faddish about such details as food, bath and exercise, irritable without cause, and sullen when Through health supervision of children and adults who show these and other symptoms of disordered minds, through coopera- tion with educational and other State authorities, much may be accomplished in the prevention of insanity. The personal initia- tive and resourcefulness of the public health nurse will be the determining factors in many instances of the degree to which dis- aster threatening persons in this class will be obviated. Such persons should be taken or sent to the free clinics in mental hygiene which are maintained in nearly every district of the State in connection with the State hospitals. The local public health nurse should write to the State hospital for her district, or to the State Hospital Commission for information concerning the loca- tion of these clinics and the name and address of their field agents. These clinics and field agents for promoting mental hygiene have comparatively recently been greatly increased and •Transactions of the Fifteenth International Congress on Hygiene and Demography. Public Health Nursing 221 more generally em2:)loyed. Thev meet a great need in the field of preventive medicine. The Mental Defective In studies conducted by the Eesearch Department of the Train- ing School for Mental Defectives at Vineland, New Jersey, b per cent of the children in the first five grades in school wert- found defective, and 15 per cent proved to be backward. (Many cases of backwardness may be remedied by removal of hypertrophied and diseased tonsils, and adenoids, and by treat' ment of defective hearing, anemia and rickets.*) Rural surveys made by nurses from the State Department of Health have shown in every community the presence of mental defectives. In certain isolated school districts the majority of the pupils are of low grade mentality. In one district with 135 school children in 7 schools a test of their mentality showed 6 feeble-minded and 2 epileptic. In one township with a population of 1,127 there were found 5 epileptics one of whom is an imbecile and 29 feeble- minded persons. Defective mentality is directly responsible for an incalculable amount of poverty, vice (including alcoholism and venereal dis- ease) and crime. The public through State, municipal or private funds must pay the price of this condition. Frequently the pay- ment is made through destruction of property and economic waste. Statesmen, educators, and other social agents are seeking to give adequate care and supervision to this class of persons. Adequate care involves educational supervision, and training with custodial care when necessary; and through colonization, pre- vention of reproduction of their kind, while allowing the largest possible amount of individual freedom and usefulness. To accomplish this several State institutions have been created for epileptics, misdemeanants, delinquents and other children and adults of defective mentality. The school nurse should cooperate with local agencies to secure the fullest possible education of these children, bearing in mind, however, that since defective mentality is incurable, the nurse's work generally will not only be economi- cally more efficient, but also produce a better citizenship if per- manent custodial care can be provided for these unfortunate Dr. H. H. Drysdale, Cleveland Medical Journal, Vol. IV, No. X. 222 State Department of Health persons. It costs the State less than $175 per year to care ade- quately for its mental defectives. What it costs to care for them inefficiently in the home can not be computed, the toll being ex- acted not only in cash, but also in suffering in which those not mentally defective are also involved. Paragraph 68, State Charities Law, provides that feeble-minded children may be received into a State institution for the feeble- minded upon the official application of a county superintendent of the poor or the commissioner of charity of a city, and that in snch admissions preference shall be given to indigent children. Paragraph 94, Art. 7 of the State Charities Law provides that " superintendents of the poor of the various counties of the state may commit to an asylum for the custody, maintenance, training and treatment of such persons " if vacancies exist therein, feeble- minded persons and idiots in their respective counties. Insane idiots and epileptics are, however, sent to insane hospitals. The maintenance of all such persons becomes a charge upon the State if the parents or guardians are unable to pay for same. Paragraph 461, Art. 22 of the State Charities Law provides that " on application of a parent, guardian, friend, or relative, or of any poor law official, or of any probation or parole officer, or of any superintendent or principal of schools," it shall be the duty of the judge of a court of record to set a date of hearing to determine the mental status of the alleged feeble-minded child. If it appears to the judge that it is to the best interest of the individual and the community that the person shall be committed to a public institution for the care of such persons the judge may make the commitment. The State Commission for the Focblc-minded, the State Board of Charities or the State Charities Aid Association should be called upon for advice whenever the nurse does not know how to proceed in dealing with this class of defect. Many counties have Agents for Dependent Children and Children's Aid Societies to handle such cases. Often tuberculous children and parents are also defective men- tally. The tuberculous condition should not be the one first con- sidered in such cases, for expense involved in caring for these children in open air schools is often wasted, the children relapsing Public Health Nursing 223 within a few weeks after returning to their homes. In all such cases from a purely economic standpoint, and surely for the permanent welfare of the child, counsel should be sought from a psychiatrist, and every effort made to induce parents to consent to the treatment prescribed. There is a Stat© Colony for the Care of Epileptics. Any moral pervert, habitual plotter of mischief, or otherwise delinquent child should be regarded by the nurse as probably mentally defective, and should be taken to a psychiatrist for examination. The counsel of the State Medical School In- spector of the State Department of Education, or of the 'New York State Commission for the Feeble-minded, should be sought if a proper examination for diagnosis can not be locally provided. Quite frequently there will come to the attention of the public health nurse instances where minors who have been in special classes for the subnormal have left school at the earliest allowable date, and lacking the guidance which they had in school, they have drifted into back eddies of the community, there to be a source of positive harm to others. The fact that at the present time there is inadequate institutional space provided for these unfortunate children should not deter the nurse from taking up each case with the iState Commission for the Feeble-minded. Frequently pro- vision can be made to safeguard the child and the public. More- over adequate provision can not be expected if actual needs for care of this class of persons are not known. 224 State Departmiint of Health CHAPTER XVni Hygiene of Home and Workshop To improve the immediate onvironment of persons in their homes' and places of daily occupation is one of the most important objects of sanitary supervision. Bad housing conditions, over- crowding, filthy and dirty habits, and lack of proper light and ventilation, reduce individual resistance and thus favor the trans- mission of all kinds of communicable disease, especially tuber- culosis. At the same time improvement of such conditions is often one of the most difficult problems vs^hich health authorities have to meet, because they are interwoven not only with estab- lished structural defects in buildings, but also with confirmed habits of living and indifference of the people themselves. Hence this problem will require for its solution a persistent campaign of popular education, the result of which, while far reaching in its effects, must necessarily be slow. Housing The teiTQ " housing " broadly considered, properly includes all conditions in ordinary dwelling houses, in factories, schools, public buildings, and structures of all kinds; but it is usually applied more particularly to dwelling houses and the conditions found inside of the home in contradistinction to conditions outside of or surrounding the dwelling. In dealing with housing conditions such questions are to be considered as the hygiene of the home, — how people live, whether in a cleanly or uncleanly manner ; the size of the dwelling quarters and the number of people occupying a room; whether the house is out of repair or lacks windows; and whether it has proper heat- ing facilities, protection against fire, etc. In all these conditions the public health nurse can do a great deal through helping to raise the standard of living by means- of popular instructions in the home. The following are the chief unhygienic conditions to be observed : 1 Overcrowding. CK^ercrowding offers increased opportunities for transmission of disease by direct contact and favors uncleanli- Public Health iSTi: using 2:25 uess, bad ventilation and other factors which are conducive to indirect transmission of infection. Coniniuuitj congestion, or the overcrowding of dwellings on a limited area of land, as with tenement houses, cuts off light and air, and leads to other dis- advantageous conditions. Family congestion, or room overcrowd- ing, is more important in its effect upon health. The size of rooms for dwellings is somewhat of an economic question and it? regulation is an exceedingly difficult administrative problem, but health authorities have a clear duty to perform in restricting the number of persons who may occupy a certain air space, in making regulations regarding the constiiiction of new buldings and in requiring necessary alterations of old ones. Theoretically, the rooms should be large enough to allow the air to be replaced two or three times an hour without causing perceptible drafts. This would require a minimal air space of from 700 to 1,000 cubic feet per person. Very few rooms in ordinary dwelling houses, however, are found with more than 600 cubic feet of air space per person, and many with scarcely half as much as this. But however large the space may be, the air will become impure unless fresh air is allowed to circulate, and however small the space the air may be kept reasonably pure by sufficient circula- tion. Movement of the air is therefore of greater importance than the size of the room. •2 I n cleanliness. Uncleanliness is even more undesirable than overc^o^^■ding as a factor in disseminating disease by direct con- tact. Moreover, both directly and through their physiological action, personal uncleanliness and unclean conditions in them- selves undoubtedly exert a depressing effect on human beings, esyjecially upon children and sensitive or delicate adults and thus also act as contributing causes of disease. 3 Lack of proper ventilation, light, etc. Under this head may be included a number of remaining conditions referring chiefly to ventilation. The lack of light has more of an indirect than a direct effect in favoring uncleanliness; darkness being usually associated with dirt, dampness, and faulty ventilation. Light is for this reason as necessary to health as cleanliness and fresh air. Light, especially direct sunlight, is a valuable germicide. A room or dwejimg into which the sun never shines can not be health- ^ 8 226 State Department of Health ful and those who inhabit dark, damp apartments soon become pale and sickly, like plants that are kept in a cellar. A dwelling in need of repair is not always an indication of poverty, but is often evidence of the low standard of living of its occupants. Such houses are not infrequently centers of disease and infection. 4 Plumhing inspection. Modern sanitary science does not place much importance upon plumbing inspection from the health standpoint except insofar as it relates to human excreta. Sewer gas, once a hygienic bugaboo, is no longer considered really dangerous, however disagreeable its odors may be. Nevertheless, such odors should not exist as they are usually an evidence of imperfect plumbing fixtures. The public health nurse should therefore look for any evidences of leakage around such fixtures, and should note general conditions and whether proper provision is made for the disposal of the wastes. 5 Types of dwellings. The principal types of dwellings are: (1) The one-family house, which is the ideal dwelling from a sanitary point of view, especially if built detached. (2) The two-family house, of which there are two kinds: (a) the double house with a party wall or division in the middle, with separate entrances on each side, each family occupying one-half the house; (b) the double house in which one family occupies the ground floor and possibly the basement, and another family occu- pies a second and sometimes a third floor, with separate entrances for each family. Such dwellings may be quite as satisfactory from a sanitary standpoint as one-family houses. (3) Tenement houses. Dwellings are usually classed as tene- ment houses when more than two families live independently but share common stairs or hallways. The tenement house exists in all large cities in this country. The suburban dwelling may eventually be so developed and cheapened in some localities as to do away, partially at least, with the groat demand for tcnonicnts. Tenement houses, however, should be under the conti-ol of health and housing authorities, (like the Tenement House Commission in this State) which should regulate their construction and care, and the building of new tenements should be discouraged in those places when there is- no economic need for their existence. Public Health Nursing 227 The housing problem, however, is not confined to any one type of dwelling. The conditions found in houses technically classed as one or two-family houses, are often quite as bad as those found in tenements. These conditions may be due to faulty construction or care by the landlord, or to the crowding of more than one family into a " one-family " house, or to more than two fami- lies into a " two-family " house (especially in growing industrial communities). There is the lodger problem to contend with everywhere in all types of dwellings. (4) Public buildings. Public buildings such as schools, churches, theatres, moving picture shows, factories and workshops, public baths, court houses and other municipal and state build- ings, require attention chiefly in relation to cleanliness, lighting and ventilation. Of these ventilation is the most important, for in buildings of this class proper ventilation is the exception rather than the rule. Owing to the fact that great numbers of people spend many hours of each day in such places, this is a distinctly important field of work for the public health nurse and for other public health inspectors. Ventilation Ventilation is commonly supposed to be a very simple matter, viz., to furnish a continuous stream of fresh air from the atmos- phere outside of the house to replace that which is constantly being vitiated inside. But to do this under the artificial condi- tions in which people live and work is often extremely diSicult, if not sometimes impossible. Ventilation to be satisfactory must serve a number of purposes and comply with a number of conditions : ( 1 ) It must bring pure air from without in order to dilute the products of respiration as well as the other sources of vitiation; (2) it must maintain the air within the room at a proper temperature and humidity, and further, must keep the air of the room in gentle, continuous motion; (3) it must remove the gases, odors, bacteria, dust and other substances that contaminate the air of inclosed spaces, aiid the impurities produced by the burning of ^as. caxidies, iainpg 228 State Department of Health and other sources of illummation. The purpose of ventilation, in other words, is not so much to bring out-door conditions indoors as to adapt indoor conditions to indoor life, wiiich is necessary in order to perform the kind of work which can not, as- a rule, be effectively carried on outdoors, involving quiet and protection from sudden changes and extremes of tempera- ture, etc. The mechanical problem of regulating the temperature and humidity within narrow limits and of furnishing definite quan- tities of fresh, moving air is not difficult for the ventilating engi- neer to solve, but to maintain those conditions necessitates the shutting of doors' and windows. The conditions inside and out- side of the room to be ventilated are not constant, depending upon the force and direction of the wind, the changes of outdoor tem- perature and to less extent, the air movements within the room. Allowance for these conditions must therefore be made, which can not be done with open windows and doors by any system of ventilation. The efficiency of ventilation is measured by the results obtained at the breathing zone. Provided the heated, moistened and vitiated air which surrounds us is constantly removed and replaced with a fresh supply properly conditioned, it does not matter what the air is near the ceiling. Moreover, the air brought into the room must be clean, not smoky, dusty or laden with bac- teria, or contaminated with gases or odors if the ventilation is to be satisfactory. The sources of the air, for this reason, must always be considered as of great importance. Ventilation and heating are also closely related. Clean air in motion and of proper temperature and htimidity is necessary to indoor comfort. Satis- factory ventilation thus not only takes into consideration the physical condition of the air, but also demands a generotis supply of fresh air. The inhabitants of climates like ours are apt to live under artificial conditions in over-heated houses, and often complain of poor ventilation, regardless of whether the air supply is large or small. Our dwelling houses are usually constructed without any regard to ventilation, which requires just as much care and fore- Public Health litjRsiXG 229 thought as the system of heating the house or supplying it with watex, gas or electricity, or the proper disposal of wastes. There- fore, whatever system of ventilation is employed in a house, the public hoalth nurse should, if possible, see that sunshine is ad- mitted and that the rooms are frequently flushed with fresh air. When a room smells stuffy and close it may be taken as a fairly reliable index that the air is vitiated. The odors observed upon entering a room from the outside fresh air often furnish better evidence of imperfect ventilation than laboratory tests. The size and shape of the room are very important factors in any system of ventilation. The minimal space should be about one-third the quantity of air required per hour ; that is, from YOO to 1,000 cubic feet per person. The amount of space naturally varies' with dwellings, factories, schools, prisons, hospitals, etc., also with the length of time the room is occupied and the nature of the work there carried on. But the regulation of space is by itself of little value, unless there is movement of air. A small space is sufficient if properly ventilated ; a large space inadequate if improperly ventilated. ,I^or is it the air space of the room alone that influences ventilation ; a lofty room is not necessarily an airy room, for a stratum of warm vitiated air soon occupies the upper portion of such space, and, so far as good air is concerned, has the effect of lowering the effective height of the ceiling to the top of the window or door. Floor sjjace is much more important than height. According to Harrington, when the allowance is only 500 cubic feet per person the floor space should be 42 sq. ft. (8^^x53/^). Ordinarily 9 ft. is high enough for the ceilings of private dwell- ings, and 12 ft. for schools, etc. Inlets and outlets should be provided, whatever system of ven- tilation is employed ; proper inlets for the fresh air and outlets for the vitiated air. Whether the air is to be admitted near the floor and taken out near the ceiling or vice versa is a question much discussed among ventilating engineers. Perhaps the best arrange- ment is to have the inlet above and the outlet below, both on the same side of an inner wall. Y*^ntilating ducts usually extend up the walls of the building through the roof, and should be hooded at the top. 230 State Department of Health Natural ventilation is that which depends upon openings such as doors and windows, and upon the air that comes through the pores of plaster, brick and stone, through floors and ceilings, and the cracks and crevices about window frames, etc. N"atural ventilation is better in winter than in summer owing to the greater differences in temperature. On a hot, calm day it may amount to nothing. If there is too much moisture in the air of rooms it settles upon the pores of building materials. Eain has a similar effect. Ventilation is also impeded by oil and paint and by wall paper. Excessive near])y foliage and narrow streets with high buildings act as outside obstacles. J^atural ventilation may be favored by simple devices' which may be placed at the top or bottom of windows to allow the entrance of fresh air and the exit of vitiated air. Mechanical veniiUdion or '' artificial " ventilation depends upon one of the three following methods: (1) j^lenum system which consists in the mechanical propulsion of air into the room ; (2) vacuum system, which consists of the mechanical extraction of the air out of the room; (3) a combination of the plenum and vacuum systems. Air may be forced into a room either by means of a wai-ming apparatus or by mechanically propelling the air by means of rotary fans or " blowers." Every heating apparatus acts also as a ventilator, especially hot air furnaces and the direct-indirect system in use with hot air or steam pipes. Open firepbiees, stoves, etc., are also good ventilators, if properly constructed. The dis- advantages of the mechajiical systems of ventilation are that they are expensive to install and maintain, and furthermore, they ai*e designed to work only when all the doors and windows are kept closed. On the other hand, they are effective in all kinds of weather and require less space than natural ventilation. Heating Heating aiul xcntilation <;() liand in hand, so nnie]i so that if ventihition is overdone, it causes unnecessary expense in heating. Many of our houses are overheated with abnormally dry air in the winter time. This causes excessive evaporation from the skin, giving rise to a sensation of chilliness. Tt also causes at times Public Health Nursing 231 disposition to colds and other reppiratory infections. Warm dry air does not give the same sense of warmth and comfort as does a cooler moist air. Air at 62° to 65° F. and a relative humidity of 70 per cent feels warmer than air at 70° to 72° F. and a rela- tive humidity of 50 per cent.* Furnace, hot water, and steam heat tend to dry the air. Hence our houses and offices have to he overheated to make them comfortable unless some form of ventilating apparatus is used. Both thermometer and hygrometer should be provided — in fact the hygrometer to give the humidity readings is quite as important an instiTiment to have in the home or workshop as is the thermometer to indicate the temperature. f The chief methods of heating are: (1) Open fireplaces; (2) stoves; (3) hot air; (4) hot water or steam; and (5) electricity. The control of the temperature of a building is of more impor- tance tlian the system of heating used. Open fires heat mainly through direct radiation, and have the advantage of being cheerful and serve as good ventilators, but they are wasteful and give a very uneven temperature if depended on alone as a source of heat. FranJclin stoves consist of coal fires in a cast-iron stove with a pipe to carry off the products of combustion. They stand free in the room, and are very efficient as a source of heat but the heating is unequal. Such stoves when red hot are believed to allow carbon monoxide to pass through the cast-iron. Open gas heafers without ilucs to carry off the products of com- bustion are bad from a sanitary standpoint. Such heaters may contaminate the air with carbon monoxide from leakage or from unconsumed gas ; they also give off carbonic acid gas and other products. Open heaters burning oil are less objectionable than gas heaters. * The Chicago indoor humiditv Joard of Health published a table designed to show desirable in the American home as follows: Degrees of temperature 60° F. 66° F. 68° F. 79° F. .34-40 72° F. Per cent relative humidity 64-74 50-54 40-48 30-34 tAniierican Journal of Public Health. Vol. VI, No. G. 232 State Department of Health Hot air furnaces consist of coal stoves which heat a series of tubes or plates in the dome over which air from the outside is passed. It comes in contact with the hot surfaces and is then conducted by a series of flues into the rooms of the house. A liot air furnace of this kind constantly caiTies fresh air into the house, and is, therefore, a veiy efficient system of ventilation. The objections to the hot air furnace are that the air becomes exces- sively dry and frequently is " burned " in passing over the heated surfaces in the dome, thus causing an unpleasant odor in the house. If sufficiently large pans of water are placed in the fur- nace to allow adequate evaporation of moisture, this dryness may be overcome, but the water pans provided are frequently inadequate. Hot ivater and steam systems are a simple and effective means of heating buildings. The hot water system is especially ai:>plicable to small buildings and steam pipes to large buildings. The former is the more expensive to install on account of the greater amount of radiation required, but requires less fuel and is more easily regulated than a steam system which has a tend- ency to overheat. If the hot water pipes or steam coils are exposed directly in the room, the system is known as " direct." If the pipes are placed in a special box where the air from the outside is heated and then conducted into the room, it is call(\i the " direct-indirect " system. In l)oth of these systems the air is abnormally dried but not to such a degree as with the hot air furnace. Electric heating is clean and easily regulated, but expensive. It has the disadvantage of being insufficient as a ventilating device. Cooling of rooms has untilrecontlyreceived very little attention, but it is quite as practicable to cool rooms as to heat them and sometimes as important to health. The principle of all cooling devices depends upon the fact that when a fluid is transformed to its gaseous state it absorbs latent heat which is taken from the sur- rounding objects, aud those, therefore, become correspondingly cool. Ammonia gas is now almost universally used in freezing machines for cooling refrigerators, cold storage rooms, etc., in this way. Humidifiers and air washers are also used to cool rooms and Iniildings. A simple method of cooling a room is to hang a Public Health Kuesing 283 sheet, about a yard or more wide, near the ceiling and keep it con- stantly moistened by a stream of water flowing over it. Evapora- tion is brought about by blowing air on the wet sheet ]>y meaus of an electric fan. Lighting Provisions should 1)6 made in all dwelling houses for an abun- dant supply of sunlight. Every room should have, if possible, at least one window receiving the sun during some portion of the day. It is not sufficient to give an ample window-space, which should be in proportion of one to five or six of floor space, but the immediate surroundings of the house must be taken into account. Thus, close proximity of other buildings or of trees may prevent sufficient light entering a room, although the window- space may be in excess of that required under ordinary circum- stances. Light is as necessary to health as fresh air. " Where the sun cannot enter, the doctor does," is an old Italian proverb. " The man who plants a tree in front of his house begins to dig his own grave," is another saying. Xot only living rooms and dwellings, but churches, schools, lec- ture halls, courts of justice, and all places where many people congregate, must have plenty of light as well as good ventilation, in order to be healthful. Pecent investigations have shown that coal-gas or its products in indoor air are dangerous even when existing in very small quantities. This danger has increased with the introduction of the more modern water gas, which contains 30 per cent of carbon monoxide. Illuminating gas may readily pass from a broken gas main through the soil into the cellar of a house; this is aided by the suction and j)umping action of the heating apparatus in the cellar. In passing through the soil the gas may be robbed of its characteristic odor, thus rendering it less easy of detection. Again, the gas pipes and fixtures in a dwelling may become leaky from a faulty stopcock, from rubber tubing used for drop lights, etc. For this reason, one should note the condition of the gas piping and fixtures especially in tenements, but also in one and two-family houses and public buildings. Attention should be paid to possible leaks in entering mains underneath houses, from which gas may arise and permeate the dwelling, unperceived 234 State Departmext of Health or disregarded by the tenants. Such inspections require no apparatus beyond a fairly keen sense of smell, and can be readily made during a plumbing inspection. Illuminating gas is much more dangerous than sewer gas. The electric light is probably open to less objections on the ground of danger than any other of the illuminating systems men- tioned. The advantages of the incandescent light, besides the brilliant white light it gives, are that it is steady and does not produce much heat, and that it does not pollute the air with car- bon dioxide and other products of combustion. Industrial Hygiene Industrial hygiene or hygiene of the work shop is one of the most important subjects in public health, as it deals with the health and welfare of a large portion of the population. In ISTew York State the field of industrial hygiene is assigned to the Industrial Commission for investigation and protective regulation, with definite administrative machineiy specified for the purpose, as indicated by the following sections of the Labor Law : ARTICLE 3 § 4(K hulustrial commission created. — There shall l>o a depai-tment of labor, the head of which shall be the industrial commission. The commission shall consist of five commis- sioners appointed by the governor by and with the advice and consent of the senate, one of which shall be designated by the governor as chaimnan. § 42. Bureaus. — The department of labor shall have the following bureaus: inspection; statistics and information; mediation and arbitration; industries . and immigration; employment; workmen's compensation; women in industry; and such other bureaus as the conunission may deem nccessiiiy, siilijcct to apj^ropriation by the legislature. Each bureau and division of the department and the persons in charge thereof shall be subject to the su|>eiwision and direc- ti(m of the conunission and of any connnissioner duly desig- luitod to su])ervise the work of such bureau, and in addition to their respective duties, as prescribofl l)y this chapter shall perform sncli other dnties as may be assigned to them l)y the commission. Public Health Nursing 235 § 51-a. Rules and regulations. — (1) The commission shall have power to make, amend and, repeal niles and regula- tions for carrying into effect the provisions of this chapter, applying such provisions to specific conditions and prescrib- ing means, methods and practices to effectuate such provi- sion. (2) The commission shall have power to make, amend and repeal i-ules and regulations for proper sanitation in all places to which this chapter applies, and for guarding against and minimizing fire hazards, personal injuries and diseases in all places to which this chapter applies, with respect to a. The construction, alteration, equipment and mainte- nance of all such places, including the conversion of struc- tures into factories, factory buildings and mercantile estab- lishments ; b. The arrangement and guarding of machinery and the storing and keeping of property and articles ; c. The places where and the methods and operation by which trades and occupations may be conducted, and the con- duct of employers, employes and other persons ; It being the policy and intent of this chapter that all places to which it applies shall be so constructed, equipped, arranged, operated and conducted in all respects as to provide reason- able and adequate protection to the lives, health and safety of all persons employed therein, and frequenting the same, and that the commission shall from time to time make such niles and regulations as will effectuate such policy and intent. (3) Whenever the commission finds that any industry, trade, occupation or process involves such elements of dan- ger to the lives, health or safety of persons employed therein as to require special reg-ulation for the protection of such persons, the commission shall have power to make special rules and regulations to guard against such elements of dan- ger by establishing requirement as to temperature, humidity, the removal of dusts, gases or fumes and requiring licenses to be applied for and issued by the commission as a condi- tion of cari-ying on any such industry, trade, occupation or process and requiring medical inspection and supervision of persons employed and applying for employment, an<:l by other appropriate means. (4) The i-ules and regulations may be limited in their application to certain classes of establishments, places of employment, machines, apparatus, articles, processes, indus- tries, trades or occupations or may apply only to those to be constructed, established, installed or provided in the future. 236 State Department of Health (5) The rules and regiilatious of the comiiiissiou shall have the force and eii'ect of law and shikU be enforc-ed in the same manner as the provisions of this chapt-er. {(y) Ko provision oi this chapter specifically conferring power on the commission to make rules and regulations shall limit the power confeiTed by this section. § 53. Bureau of inspection; hispector general; divisions. The bureau of inspection, subject to the supervision and direction of the commissioner of labor, shall have charge- of all inspections made pursuant to the provisions of this chapter, and shall perfoi-m such other duties as may be assigned to it by the commissioner of labor. The first deputy commissioner of labor shall be the inspector g-eneral of the state, and in charge of this bureau subject to the direction and supervision of the commissioner of labor, except that the division of industrial hygiene shall be under the immediate direction and supervision of the commissioner of labor. Such bureau shall have four divisions as follows: factory inspection, homework inspection, mercantile inspection and industrial hygiene. There shall be such other divisions in such bureau as the commissioner of labor may deem neces- sary. In addition to their respective duties as prescribed by the provisions of this chapter, such divisions shall perform such other duties as may be as&igTicd to them Iw the com- missioner of la])or. § 54. Inspectors. — 1. Factory inspectors. There may be appointed not more than two hundred and twenty-five fac- tory ins]>ectojs, not more than fifty of whom shall he women, within the appropriation granted by the legislature. Such inspectors shall be appointed by the commission and may be removed by it at any time. The inspectors shall l^e divided into seven gi*ades. * ■?:- * •;<- * * Of the inspectors of the seventh grade one shall be a physician duly licensed to practice medicine in the state of I^ew York, and he shall be the chief medical inspector : one shall be a chemical engineer ; one shaJl be a mechanical engi- neer, and an expert in ventilation and accident lu-eveution; and one shall be a civil engineer, and one an expert in fire preventioru § GO, Divbiion of industrial hi/giene. — The ins]>ectors of the seventh gra'de shall constitute the division of industrial hygiene, which shall be under the immediate charge of the commissioner of labor. The commissioner of labor mav select Public Health Nuesing 237 ouo of the inspectors of the seventh grade to act as the dii'ector of such, division. * * * Xhe members of the division of industrial hygiene shall make special inspections of factories, mercantile establishments and other places sub- ject to the provisions of this chapter, throughout the state, and shall conduct special investigations of industrial processes and conditions. The commissioner of labor shall submit to the industrial board the recommendations of the division regard- ing i>roposed rules and reg-ulations and standai'ds to be adopted to carry into effect the provisions of this chapter and shall advise said board concerning the operation of such i-ules and standards and as to any changes or modifications to be made therein. The members of such division shall prepare material for leaflets and bulletins calling attention to dangers in particular industries and the precautions to be taken to avoid them; and shall perform such otkefr duties and render such other services as may be required by the commissioner of labor. The director of such division shall make an annual i-^port to the commissioner of labor of the operation of the division, to which may Ije attached the individual reports of each member of the division as above specified, and same shall be transmitted to th-e legislature as part of the annual report of the comiuissioner of labor. § 61. Section of medical inspection. — The inspectors of the sixth grade shall constitute the section of medical inspection which shall, subject to the supervision and direction of the director of the division of industrial hygiene, Ise under the immediate charge of the chief medical inspector. The sec- tion of medical inspection shall inspect factories, mercantile estalilishments and other places subject to the provisions of this' chapter throughout the state with respect to conditions of work aifecting the health of persons employed therein and shall have charge of the physical examination and medical supervision of all children employed therein and shall per- fonn such other duties and render such other services as the commissioner of labor mav direct. Industrial hygiciie constitutes in itself a separate branch of sani- tary science, in which various medical, economic, and sociologic aspects are closely interwoven, and which can not be handled in a cursory manner or without intimate knowledge of the conditions involved. jMoreover, the problems of each community -present in- dividual characteristics depending upon local conditions, which 238 State Departimient of Health should be the subject of special study, iu order to determine their effects on the public health. One of the results of the creation of general industrial, part-time and unit-trades schools to be admin- istered by the State Department of Education, schools which will participate in State and Federal aid, compulsory physical educa- tion and compulsory medical inspection, will be the extension of good health education and supervision to working minors and to adults required to attend instruction in these schools. Medical in- spection of factories- and mercantile establishments and health supervision of children employed therein are administered under the Labor Law, (See section 61 of Labor Law.) The public health nurse will therefore be more concerned with those factors which pertain to personal or private hygiene, and which can be best dealt with by populair education in the home, than with those of a public nature which can be controlled only by definite pubjlic; a,uthorities. iBut sine© she may be required to assist in the prevention and supeiwision of the diseases of occupation, she should have a general knowledge of the prob- lems involved. Peoblems The problems involved in industrial hygiene relate to hours of labor, to fatigue under various conditions, to the labor of women (and of children) as it affects both them and their offspring. In workshops, as in dwellings they deal with tlie subject of ventilation, of detrimental substances in the air, such as dust, fumes, gases, etc., of cleanliness and decency, and of communication of diseases, as by spitting and the like. In addition there is a large class of problems of a more special nature relating to diseases of occupation which are to be prevented or controlled, each different industry exerting its own particular effect on health. Besides the actual sanitaiy conditions, there are also questions of safety and of social welfare of the workers, which are also related to those of health. Every community, how- ever small, has its industrial problems which can not be neglected for even whea-e there are no factories, properly speaking, there are always such establishments as bakeries and other places where food is prepared, laundries, stores, etc., in which the health of the workers is an important consideration. Bakeries and Public Health Nuesing 239 laundries also come under the supervision of the State Industrial Commiasion. (See Pars. 117 and 92 of Labor Law). The enforcement of the Labor Law relative to the ouiployiiient of women and children in mercantile estahlishments in all cities is under the jurisdiction of the Industrial Commission. Enforce- ment in villages of 8,000 or more population is under local boards of health. Occupational Diseases Occupational diseases have been classified by Oliver as follows: (1) those due to gases, vapors and high temperature; (2) those due to conditions of atmospheric pressure; (3) thoso due to metallic poisons, dusts and fumes ; (4) those due to organic or inorganic dust and heated atmosphere; and (5) those due to fatigue. This is, of course, an arbitrary classification, to which may be added those diseases due to lighting condition in relation to eye strain, aaid those due to noise in relation to nervous disorders. Among the more common diseases of occupation may be men- tioned : Poisoning by lead, phosphorus, arsenic, mercury, and brass; caisson disease; and parasitic diseases such as anthrax (wool sorter's disease) and hook worm disease (miner's anemia). The relation of dusty trades and other depressing industrial con- ditions to tuberculosis is a very important aspect of the problem and one in which the public health nurse should be particularly intei'estcd, for tuberculosis is frequently found among workers in dusty trades. The problem of tuberculosis is so closely bound up with personal habits and home life, that it is quite as proper to consider it a house disease as an occupa- tional disease. Statistics show, ho\vevei\ lli.it tuberculosis is unusually prevalent among grinders, engravers, compositors, stone workers, millers, bakers, plasterers, brass workers, glass cutters, furriers, weavers, and persons in other trades in which there is undue exposure to dust and irritating vapors. Much of the dust raised in industrial processes may be limited by improvements in machinery and preventive devices such as' the wet processes. Certain dusty operations may be conducted in inclosed hoods or special cal)inets so as to confine the dust and thus protect the workers, or the dust may be removed by sue- 240 State DErARTjsraisrT of Health tion fAii devices. Good ventilation greatly diminishes the danger. When workin^'n are compelled to stay in diisty atmospheres they should wear respiratory masks. The dangerous eifects of irritat- ing or poisonous gases may he prevented by wearing special gas masjiks. The trouble is to make the workmen wear these masks ; they prefer taking chances to wearing uncomfortable respirators. — until, perhaps, it is too late. In j^ew^ Yo.rk State physicians are required to report to the State Industrial Commission all cases of industrial poisoning or disease which come to their attention. (See Article 5, Section 65 of the Labor Law.) Public health nurses should make themselves familiar with terms and conditions applying to industry as specified in the Labor Law. Copies of this law and of the rules and regulations established by the State Industrial Commission may be had on application to the Commission. INDEX PAGE Abatement of insanitary conditions 23 nuisances 32-33 Abortions J[JO Adenoids, effect of ^•^' Adolescent children, minimum standards for 184 Adulteration of milk 42 detected by specific gravity test 44 Advertising health ^^^ After-care of discharged tuberculosis sanatorium patients US of infantile paralysis ^211 Agents in transmission of disease 23-24 American Red Cross, field of 3^ Analysis of water, chemical 58 sanitary 58 Antitoxin, diphtheria 140 outdated packages 140 treatment 142 tetanus _• ^^^'^^J Aseptic precautions in cases of communicable diseases .• ■ • • ^ Authority for employing public health nurses by state commissioner of health 5 by health officers <| by boards of trustees G by boards of education 6 by county tuberculosis hospital 6 and legal status of public health nurse 10-11 of local boards of health to make regulations 95 Bacillary dysentery 14j^ Bacteria in milk 40 water 53 Bacterial count of milk 41-42, 46 Bacteriological examination of water 61 reports of water examinations '52 Barnyard conditions -■^ Bed bugs, extermination of ^2 Birth certificates 166 Births, reporting by midwives 187 imreported 1^^ Blind child, education of 207 Blindness and sore eyes 197 reporting 19^ prevention and relief of 198 Blood examinations for typhoid fever 14-^ paratyphoid fever 146 dysentery _ 1 4*") malaria organisms • • 147-14S' Board of education, England's recommendations for instruction in infant care "^"Jo^o? Breeding places for insects o Burnham, William, characteristics of sane mind 219 Campaign, publicity Y^ for cleanliness "^^ '^" organizing a tuberculosis 128 [241] 242 IXDEX PAGE Carriers of diseases, diphtheria 144 dysentery 146 investigation 50 Cerebros2>inal meningitis 14S Cesspools 73 Channels and modes of infection, investigation of 1!) Characteristics of sane mind 2 If) Charities law governing care of feeble-minded children by State.... 222 commitments to asylums 222 hearings to determine mental status of fee- ble-minded children 222 Chart, boys heiglit and weight 1S2 girls height and weight 181 Charts 155-157 Charts and maps, use of. in mailing investigations 20 Child, mother's care of 5 Children, adolescent 184 care of tuberculous 118 correction of defects in 1S>5 physical defects in 193 minimum standards for 183 Children's health centers 176 Child welfare activities of public health nurse 173-180 for infants and prescliool children 176-177 minimum standards for 174-177 Child welfare nurse 17S duties of 178-179 instruction of girls in infant care and management by. 179-180 knowledge of food values 180 relief for needy cases 179 weighing and measuring children 180 Child welfare station, functions of 17S Classification of cases of tuberculosis 1"7 Classification of water supplies 5.S Cleansing and disinfection 99 Closing schools during communicable disease outbreaks 137* Colon bacilli in water 63 Commissioner of Education may adopt rules in regard to school medical inspection 134 Commitments to asylums 222 Communicable diseases, diphtheria 141 dysentery 146 epidemic cerebrospinal meningitis 148 gonorrhea 14:> malaria 147 paratyphoid fever 14fi pertussis (whooping cough) 147 pneumonia 14S syphilis l-i*^ tetanus 14i! tuberculosis 144 typhoid fever 14(1 Vincent's angina 141 Communicable disease among school children, cooperation in the control of 131 complicating tuberculosis 121-122 control of 19-21. 94 knowledge of svmptoms bv school teachers. . 134 list of reportable ." 95-96 Index 243 Communicable disease — Continued I'^QE on dairy farms 98 outbreaks of 131-134 persons coming in contact with cases of, for- bidden to handle food for pviblic sale.... 30' prevention of "4 reporting 9.'j rules and regulations for health officers and school medical inspectors 135-137 social agencies, assistance from 103-104 spread by milk 45 Communicable diseases in schools, duties of health officer 136-137 duty of health officer to investigate unat- tended cases 135 duties of medical school inspector 136-137 medical officer shall notify health officer... 136-137 Communicable disease outbreaks, question of closing schools during. 13/ Community actwn on public health problems 150 Comparisons of vital statistics rates 162 Compilation of tuberculosis laws 117 Complement fixation test for syphilis 148 Conditions affecting vital statistics 170-171 inimical to health, study of 20 to be observed in sanitary survey 24 Conduct of isolation period 99 Conferences, attendance at 1' Contact bed for sewage purification 84 Control of communicable disea.ses 19, 21, 94, 99 cooperation of health and educational author- ities in 1*^0 fly breeding 27, 87 house drainage 28 malaria 89 rats ; ■ 90-91 Cooperation in control of communicable diseases among school chil- dren 131 physical education and health supervision 218 school medical inspection 130 Cooperation and division of duties among workers in tuberculosis family 124-126 of health and educational authorities in the control of communicable diseases 130 developed through working for common cause . iv in control of communicable disease among school chil- dren 99 publication of reports necessary to secure public v of Red Cross with local groups iv of school and health authorities 20 of school nurse with board of health 12 with other philanthropic agencies 20 with specializing nurses 103 with various charitable organizations 20 Corrected death rates 164 Correction of eye and ear defects 206-207 malnutrition 211 physical defects in children 195 County law f tuberculosis nurse 10, 12, 14, 112 Courses of instruction 1 ' Cultures for diagnosis 1*1 release 142 244 IxDEX PAOB Dairy farms, epidcjnics on 3S reporting communicable diseases on i health supervision and education of school child 18 medical inspection of school children 133 public health nursing 6 Education of blind child 207 physical .^l^ Emerson, Harrington, definition of a record and a report iv-v Employment of public health nurses by boards of education G board of trustees G commissioner of health. ... 5 county tuberculosis hospitals 6 health oflicers 5 Red Cross county chapters. iv Entrance to premises, duty if refused 12 Environment not source of infection 2:i Epidemic cerebrospinal meningitis 1"^^ Epidemics among school children • • • • 131-134: investigation of 1^ Estimates of population 1*^1 Examination of water, bacteriological 61 for eye and ear defects 19*> Examinations by state laboratory 139, 1&8 Exclusion from school in cases of communicable diseases 131 Exclusion rules, knowledge of, by school teachers 134 Excrement, disposal of human 26, 66 Expenses, record of v Extermination of mosquitoes 27, 89 Eve defects 197" tests for 19S Eye and ear tests of school children • 19S instruction to teachers 198 Fatality rate 164 Fat in milk, test for 44 Feeble-minded children, care of, by state 222 commitment of 222 hearings to determine mental status of 222 Feeble-mindedness, societies dealing with 222 diagnosis of 223 Field work 15 Filtration of sewage, slow sand 82 water sui>plies 64 Flies, methods of controlling spread of disease by 87-8^ Fly control 27, 87 breeding classified as nuisance 33 Food handling 19 by persons having tuberculosis 110. forbidden in certain cases 30 inspection of methods of 29 Fumigation, terminal 133 Functions of public health laboratory 139 Funds for tuberculosis work 129 securing of, for health activities iv Garbage disposal 26 piles 34 246 Index PAGE Gonorrhea and sypliilis 100 specimens 149 Grading milk 4S Graphs '....'.'.'. 156, 157 Habits of person having tuberculosis 110-111 Hardness in water (j(j Hard water 51 Health laws, penalties for violation of 18() literature 154 preparing copy 151 officer, duties in caises of communicable diseases in schools. 131-136 duties regarding laboratory supplies 140 duty to investigate cases of unattended communicable disease 136 must countersign school medical certificates 134 relation of public health nurse to 14 rules and regulations for, in the control of com- municable diseases in schools 135-137 to take release cultures 142 Health supervision, cooperation in 21S and education of school diild 21, 183, 192 Hearing tests 204 Heating, methods of 230-233 Height and weight chart for boys 1S2 girls ISl Home, instruction in 5 and workshop, hygiene of 21 Home pasteurization of milk 47 supervision of tuberculosis patients US treatment of tuberculosis 117 House heating 230 light, lack of 225 lighting 233 overcrowding 224 plumbing inspection 226 types of dwellings 226 uncleanliness 225 ventilation 225, 227-230 Housing conditions 25, 224-227 Household drainage 26. 66 filtration of water 65 Human excrement, disposal of 26. 66 Hygiene, industrial 234 of home and workshop 21 . 224-240 Iceless ice-box 49 Ignorance in home, menace to health 6 niuminating gas, dangers from 233' Immunity to diphtheria 143 ])aratyphoid fever 146 typhoid fever 145 Impurities in water 52-53 prevention of 63 Industrial commission 234 inspection of factories 236 diseases, reporting of 240 rules and regulations regarding 235 liygiene 234 labor law 234 medical inspection 236 poisoning, reporting of 240 Index -247 PAGE Infant care and feeding, instruction of girls in 170 management, recommendations for 170-180 Infants and preschool children 176-177 Infant mortality problem, solution of 178 rate 165, 173-174 welfare activities 20 Infection, investigation of. modes of 19 food 33 milk : 33 water 33, 50 Information regarding communicable disease 09 Insanitary conditions, abatement of 23 effect on health 23 importance of 22 prevention of 21 Insanitary homes and tuberculous cases 122-123 Insects, control of 87* Inspection of bakeries 30-32 breeding places for flies, etc 27 confectioneries 32 dairies 28, 38, 46 disposal of human excrement 26 eating houses 30 garbage disposal methods 26 household drainage methods 26 housing 25 markets 30-32 methods of food handling 29-30 midwives, directions for 187 milk supplies 28, 31, 46 mosquito breeding places 27 places where food is sold 30-31 premises by nurse 12 premises for nuisances 3'^ public buildings 227 restaurants 30 sanitary conditions, see sanitary inspection school children in absence of school nurse 94 soda fountains 30-32 water supplies 28-31 Institutions, disposal of sewage of 80-86 cases of tuberculosis in IIT Instruction, courses of. for nurses 17 in conducting isolation period in home 38 in personal hygiene in homes 5 of public in measures to prevent spread of infection. ... 10 regarding care of patient 94 to be given as result of sanitary inspection 31 Instructions for cleansing and disinfection 90 to teachers for examination of eyes and ears ' 19i5 Irterpretation of water analyses 59 Investigation of breeding places of insects 19' epidemics 16 regarding food sanitation lO modes and channels of infection 19' nuisances 11 248 Index Investigation of — Continued page sanitary conditions on dairy farms 38 sewage and waste disposal H> water supplies 19, 50 Investigations, for discovery of unreported cases of communicable disease 20 Iron in water 52 Irrigation system of sewage disposal 74-79 Isolation of cases of tuberculosis 109 Itch mites, extermination of 9.3 Jr.niijr health officers, for school rooms 134 reports 133 Laboratory examinations 139 diphtheria 142 dysentery 146 Ijaratyjihoid fever 14fi smears froni sore eyes 19^ tuberculosis 144-145 typhoid fever 145 Vincent's angina 142 Laboratory, local 13ectors must countersign school certificate 134 school inspectors, rules and regulations for 135-137 Meningitis, cerebrospinal 14S Mental defectives 221 Mental hygiene 21, 219-223 clinics 220 defects, prevention of 21 Methods of advertising healtli 150 garbage disposal 26 securing correction of defects in children ID.) securing space in newspapers 152, 153 water filtration 6-* Midwives, birth certificates to be filed by 186 equipment of 188 inspection of 187-190 licenses 185 must keep and use ophthalmia neontariun outfits 186 must record births 187 must report stillbirths 186 penalties for failure to report births 186 violation of regulations governing practice of 186 regulation governing practice of 185 reports on inspection of 189 supervision of 20, 185 unlicensed 191 what, must do to practice 185 Midwifery, sanitary code in relation to practice of 185 penal code in relation to practice of 185 Milk and eggs for tuberculous patients 12S Milk, adulteration of 42 animal diseases contracted through 44 bacteria in 40 bacterial count of 41-42. 46 borne epidemics 31, 38-39 collection of samples of 42 composition of 43 conditions governing production of pure 39 cooling of 4/ curdling of 40 dirty, the dirt test 42 disease germs in 41 diseases spread by 44-45 grading 47 pasteurization of 46 permits for sale of 38,4.^ procedures with suspected milk 48 quality of 39 scoring of 4^6 slimy or ropy milk 41 souring of 40 specific gravity test for adulteration of 44 supply, infection of 3.*? inspection 28. 38 tastes and odors in 41 250 Index Milk — Coniimted page test for fat in 44 thin and watery 41 total solids in 44 wholesome 44 Minimum standai-ds for child welfare 174, 177, IS:^ for adolescent children 1S4 Miscarriages 160 Modes and channels of infection, investigation of 11) Monthly reports, publishing 153 Morbidity statistics 164 Mosquito breeding, classified as nuisance 33 extermination 27, 89 larvae and pupae, collection of S9 Mother and child, home instruction of, in personal hygiene 5 Movement of population 162 Municipalities, disposal of sewage of SO-SG Natural growth of commimity 161 Necessity for birth and death registration 166 Newspaper health publicity 150-151 Newspapers, methods of securing space in 151-152 monthly reports should be published in 153 rules to be observed in preparing copy for 151-152 Nonresident deaths 167 Nuisances, abatement of . 32-33 authorization of nurse to inspect 11 board of health's power to deal with 11 classification of 33 directly affecting health 33 indirectly afl"ecting health 34 other torms of 3o private drains 35 Nurse, see public health nurse and communicable disease 04 Objects of sewage purification 81-82 Obnoxious fumes 34 Occupational conditions detrimental to health 238 diseases 239 Odors from privies 34 in milk 41 in water (>i'i Ollice work of public heallh luirse 16 Official standing of public health nurse if Ijoard of health appoints as agent of health ollicer 12 Open air scliools 193 Opposition to investigation, tiibci'culosis nurse nuist report to proper authority 12 Ophthalmia neononatorum outfits 182 Organizing a local tuberc\dosis campaign 128 Orthopedic defects of childien 208-210 nurse, services of state 212 surgeon, services of state 212 Outbreaks of communicable diseases 131-134 Outdated laboratory supplies 146 Overcrowding of dwellings 225 Paralysis, postdiphtheritic 143 Paratyphoid fever 146 Part-time schools, physical cducal on in 216-217 Pasteurization of milk 4()-47 Pediculosis 91, 92 Index 251 PAGE Penal code in lelatiun to practice of midwifery 185 sore eyes 197 Penalties, for violation of regulations of sanitary code 186 health laws '. 186 failure to report births 186 Permit for sale of milk necessary 38, 48 Personal educational work 151, 158, 159 Pertussis 147 vaccine 147 Physical defects in the child 193 Physical education in schools 213 coojjeration in 218 general plan of 215-216 part-time schools 216-217 Physician, relation of public health nurse to 14 required to report conmiunicable diseases 95 Plumbing inspection 226 Pneumonia 148 serum 14S specimens 14& Poliomyelitis, after-care 211 Pollution of water supplies 50-54 source of 53 Population in relation to vital statistics 160 Postdiphtheritic paralysis 143 Practice of midwifery 185 conditions of 185-186 penalties for violations of regulations govern- ing 186 Predisposing causes of mental disorder 220 Pregnant mothers, advice to 103 Prenatal care ^ 179 centers 175-176 Press, furnishing material for 20 warnings in epidemics 133 Principles governing tlie securing of pure water supply 50 Prevention of communicable diseases 94, 99 impurities in water supply 6.> tuberculosis 10b Preventorium for tuberculosis cases 118 Privies, removable receptacle for ^^~^i types of 67 underground vault (dug) ^^~^^ watertight vault 72 Procedures to be taken by tuberculosis patients 109-110 and precautions with suspected milk 48 Protection of public health nurse for acts done in performances of dutv 12 Publications for public health nurses 99, 100, 106 Publication of reports in newspapers v Public buildings 227 Public cooperation and support, necessary for nurses v Public Health Council, qualifications established by, for state super- vising public health nurses 7 Public health education 20 by charts 155 graphs 156 literature 154 252 Index Public health education — Continued page by personal contact 158 spot maps 156 the newspaper 151 methods employed in 150 the nurse in 150 Public health laboratory 13S functions of 139 local 139 state 139 Public health laws, employment of public health nurses by board of trustees of schools ! 6 county tuberculosis iiospital fi health officer 5 state commissioner of health 5 conflict of authority regarding physical welfare of scliool children ". 130 enforcement of 14 penalty for violation of 186 published in public health manual 13 Public health manual 99 part of necessary equipment 13 Public healtli nurse i abate!)ient of insanitary conditions by 23 nuisances by 32-34 acting for school nurse . ." 94 action if refused admission to make inspection.. 24 advice by, io pregnant mothers 103 after-care of infantile paralysis by 211-212 agent of health officer \\l and child welfare activities 173-180 arousing public sentiment through 20 assignments '. 5, 6, 15 attendance at conferences 17 breeding places of insects, investigation by 19 care of pregnant women 179 collecting specimens of sputum 144 control of comnnmieable diseases 19-21 cooperation witli school and health authorities.. 20 other philanthropic agencies . . 20 specializing nurses 10.5 various charitable associations. 20 correcting malnutrition 210-211 county 112 procedure if denied entrance to premises 12 diplomacy needed by 94 division of duties with other tuberciilosis work- ers 124-126 duties in suppression of gonorrhea and syphilis. . 101-102 mental hvgiene cases 220 duties of ' S-94 in cases of sore eyes 197, 198 duty in case of unlicensed midwives 191 unreported deaths 190 to report cases of food poisoning M2 effective aid to health officer 94 employment of, by boards of trustees of schools. . 6, 12 county tuberculosis hospitals. (>. 12 health officer 5 Red Cross iv state commissioner of health. 5 Index 2oe* Public health nurse — Continued PAGE expenses 1^ familiarity with laboratory procedures 13!) field work lf> food sanitation, investigation by 1!' furnishing material for press 20 general measures used by 20 hours of duty 1^ housing problems 25 hygiene of home and workshop 21 infant care and management 179-lSO welfare activities 20 must be informed on conditions governing pure milk supply -^^ inspection of barnyard conditions 27 breeding places for flies 27 disposal of human excrement .... 26 eating houses . 30 general topography 24 methods of garbage disposal .... 26 handling food 29 household drainage . . 26 midwives 1S7-190 milk supply 28, 3S mosquito breeding places 27 places where food is sold 30 public buildings 227 milk supply 31 water supply 28, 31, 50, 53 instruction by, in methods of conducting isola- tion period 38 instruction of girls in infant care and feeding.. 179 instruction by, as result of sanitary inspection. . 31 interpretation of laboratory reports 139 investigation for discovery of unreported cases. . 20 of milkborne epidemics 38-39 of nuisances H knowledge of food values ISO industrial hygiene problems 238-239 labor laws 240 medical emergencies in cases of communicable diseases other than tuberculosis 120-122 symptoms of gonorrhea and syphi- lis 102 law jirotects against acts done in performance of duty 12 legal right to inspect premises 24 status and authority of 10 lines of work IS mental hygiene, knowledge of , by 21 must not treat sore eyes 19^ necessary knowledge of vital statistics by 160 need of compilation of information for iii office work of ^" official standing of, when appointed by board of health 1^ persoual educational work of 158,^159 powers of -. o, iz 254 I.^DEX Public health nurse — Continued page preparation of maps and charts 20 preparation of laboratory specimens for mailing 141 news stories 151 procedure in cases of subnormal children 223 tuberculosis work 106 publications for 09-100 public health education by 20 publishing monthly reports 153 qualifications of ". 7. 94 reading for 17 reasons for employment of iii relation to sanitary supervisor IS relief for needy cases by 179 reporting conimunicable'^ disease 95 inspection of midwives 189 imsatisfactory garbage disposal con- ditions 27 reports of work to proper authority v research work * 17 sanitary inspections by 22 sanitary inspection of occupied premises 24 instruction in tuberculosis cases 119 supervision of tuberculosis cases 119 surveys by 19 securing laboratory specimens 20. 31 prenatal care 179 treatment in mental cases 219 sewage disposal, investigation by 19 social work of 124 social welfare work 102-105 source of authority 12 power 5, 12 special articles by 153 special courses of instruction for 17 duties for health officer 94 study of community conditions 20 supervision of health of school children 21 midwives 20 quarantine 20 taking cultures for diagnosis or release 142 specimens from women for examination for gonorrhea 102 testing for eye and ear defects 19S-207 testing personal immunity to diphtheria 144 under direction of health officer 14 visiting homes of venereal disease clinic patients 103 vital statistics records 20 water supply investigation 19 weighing and measuring children ISO Wf)rking lilirary for 100 Public health nursing and tiibcrculosis 106 Public Health Nurses' Bulletin 100 Public health nursing in New York State 5 Publicity campaigns iv methods 150-159 Public sentiment, arousing 20 Public water supplies 50 Pure milk supply, conditions governing 39 water supply 50-51 Index 255 PAGE Furification of sewage 82-86 water 63 Qualifications of registered nurse ., 7 Qualities of a good record v Quality of milk 39 Quarantine, release from diphtheria 141 supervision of 20 Rain water 53 Rats as a factor in spreading disease 87 extermination of 90-91 Reasons for registering births and deaths 166-167 Receipts for expenses 18 Records, in tuberculous cases 129 of school nurse 132 Records and reports iv definition of iv Records, developing own system of v field notes for 16 of epidemics 16 of expenses v of inspection of places where food is sold 30 qualities of good v system of National Organization for Public Health Nursing. v tuberculosis 113 Recreation as a means of controlling gonorrhea and syphilis 104-105 Red Cross, field of iv Registered nurse, qualifications of 7 requirements to practice as 7 Registration districts 166 of births and deaths, necessity for 166-167 of midwives 185 Registrars, duties of local 166 Regulations for health officers and school medical inspectors 135 Regulations governing practice of midwifery 185, 190 release from diphtheria quarantine 141 specimens for diagnosis of typhoid fever.... 145 taking of diphtheria cultures 141 issued by local boards of health 13 issued by state commissioner of health 13 Relation of public health nurse to health officer 14 physicians 14 relief organizations 15 supervisor 18 the public 15 Release from diphtheria quarantine, regulations 141 Relief in tuberculosis cases 123-124 Reports of bacteriological tests of water 62 interpreting laboratory 139 monthly, by nurses 153 of water analyses, by laboratory 59 of Junior health officers 135 of suspected cases of tuberculosis 109, 115 inspection of midwives 189 Reporting communicable diseases 95 on dairy farms 98 industrial diseases 240 suspicious cases of gonorrhea and syphilis 102 Reports, daily 17 definition iv, 6 for health officer v 256 IxDEx Reports — Continued page nurse must keep accurato 8 of oases of food poisoning 32 conditions surrounding water supplies 50 nuisances 3;! sanitary conditions of buildings and premises 1!) tuberculosis nurse to hospital superintendent 12 to be published regularly v local boards of health 10 private agencies 10 Research work 17 Right of entrance and inspection in tuberculosis 127 Ropy milk 41 Rules to be observed in preparing newspaper articles 151-152 Salesmanship methods for health education 217-21S Samples, collection of milk or water 31, 42 collection of water 58, 62 Sanitary analysis of water 58 Sanitary code in relation to exclusion of children from school.... 131 midwifery 185 penalties for violation of regulations of 186 release from diphtheria quarantine. . 141 typhoid specimens 145 publications of changes in 10(> requires certificate for return to school after illness. 133-134 householders to report communicable diseases 133 taking cultures in cases of suspected diph- theria 141 Sanitary insiJection of barnyard conditions 27 in regard to cleanliness 25 of disix>sal of human excrement 26 fly control 27 food handling 20 garbage disposal 26 general topography 24 housing 25 household drainage 2(> milk supply ■ 2S mosquito extermination 27 occupied promises 24 water supply 28 Sanitary instruction in tuberculosis 119-120 supervision in tuberculosis 110 supervisor, relation of nurse to IS Sanitation, key notes of 10-22 Sanitary surveys 10 important points in 22 of watershed 54 water supplies 5"i Sanatorium treatment for cases of tid>orculosis 100. Ill School, communicable diseases in 135-137 exclusion from, of cases of communicable disease 131 children, mininnim stiindards in child welfare for 183 tests for eye and oar defects 108-200 nurse, cooperation in care of mental defectives 221 correcting malnutrition 210-21 I duties of, in outl)reaks of commiuiicable di.sease 132 functions and duties of 5, 10. 12. 102 nu'thods of securing correction of dofocts by 105 preventing foot (U'fecls 208-210 securing interest in open air schools 103 Index 257 School — Continued PAGE nurge — Continued suggested duties of 212 testing eye and ear defects 198-207 medical inspection and school certificates 134 in cases of communicable disease 131-134 cooperation in 130 rules and regulations for 135-137 trustees authority to close schools during communicable dis- ease outbreaks 137 Schools, desirability of not closing, during disease outbreaks 137 physical education in 213-217 Score card system for inspection of dairies 46 Securing a nurse "i laboratory specimens 20 specimens for examination for gonorrhea 102 specimens of mosquito larvae and pupae 90 Septic tank method of sewage disposal 83 Serum, pneumonia 148 Sewage and waste disposal 19 Sewage disposal, cesspools 73-74 for institutions and municipalities 81-83 system in relation to water supply 55 subsurface irrigation system 74r-79 water carriage systems of 72-73 chemical precipitation of 82-83 composition of 80 contact beds for 84 disinfection of 86 methods of purification of 82 sanitary methods of disposal of 66 septic tank, method of purifying 83-84 slow sand filtration of 82-84 sprinkling filters for 85 when constituting a nuisance 5 Schick test 143, 144 Slow sand filtration of sewage 82-84 Specific death rates 163 Smears from sore eyes, examination of 198 Smoke nuisances _ _ 35 Social agencies cooperating in suppression of communicable diseases. 103-105 Social welfare work 102-105 work of public health nurse 124 Sources of pollution of water 54 Souring of milk 40 Sore eyes 197 Special" orders, public health nurse subject to 14 Specific gravity of milk 44 Specimens, blood 145 gonorrhea 149 malaria diagnosis 147 paratyphoid diagnosis 146 pneumonia 148 securing laboratory 20 syphilis 148 Spinal puncture 148 Spontaneous pneumothorax 121 Spot maps 156 Sprinkling beds for sewage purification 85 Standard methods of milk examination 42 population 165 9 268 Index PAGE standardized death rate 164 Standards for child welfare work 174-177 State supervising nurses, duties of 9 public health laboratory, examinations made by 139 Statutory requirements, in relation to nuisances 35 Sterilization of water 63-64 StiUbirths 160, 173 Study of conditions inimical to health 20 Subnormal children 223 Subsurface irrigation system of sewage disposal 74-79 Supervising public health nurses, duties of 8 legal authority of 11 procedure if opposed 11 Supervision in control of communicable diseases 19 of health of school child 21, 183 midwlves 20, 185 ■quarantine 20 Supply stations 140 Surface water 54 Survey, tuberculosis 112, 113 Symptoms of communicable disease, knowledge of, by school teachers. 134 gonorrhea and syphilis, knowledge of 103 Syphilis 148 Wassermann test for 148 Syphilis and gonorrhea, cooperation of all authorities 104 field of public health nurse in suppression of 103-104 infected persons must not care for children, 103 recreation as means of controlling 104-105 reporting suspicious cases to family physi- cian or health officer 102 social agencies, cooperation of 103-104 social welfare work 102-105 three classes of patients 101 System of card records v sewage disposal in relation to water supply 55 Tastes and odors in milk 41 water 60 Teeth, decayed, effect on health 196 Tenement houses, control of 226 Terminal fumigation 133 Tetanus 146 antitoxin 140-147 Tonsils, effect on health of infected 196 Topography, in relation to water supplies 54 Toxin-antitoxin treatment 143 Types of dwellings 226 personality developing insanity 220 Typhoid carriers 145 fever 145 specimens 145 tests 145 vaccine 146 Tubercle bacilli in milk 40 in sputum 144 Tuberculin 110 Tuberculous cows, preventing infection from 110 children, care of 118 who are feeble minded 222 family, cooperation and division of duties among workers with 124-126 Index 259 PAGE Tuberculosis 144 after-care for discharged sanatorium patients 118 bovine 45 campaign, organizing a 128 classification of cases of 107 communicable diseases occurring in family 121-122 compilation of laws relating to 117 deaths from 106 dental service for cases of 122 discovery of cases of 113 disposition of patients 116 duty of person having 110 early diagnosis in 108 family in an insanitary home 122-123 food handling by persons having 110 habits of persons having 110-111 home supervision of cases of 118 home treatment of 117 in cows 110 institution cases 117 isolation of cases of 109 laboratory examinations for 109 laws, compilation of 117 maternity cases in family , 122 measures for prevention and control of 108 medical emergencies 120-121 milk and eggs for patients having 127-128 other forms of 127 prevention, for children 118 procedure and precautions to be taken by patients having 109-110 procuring funds for worlv in 129 records 113 relief 123-124 reports of suspected cases of 109 right of entrance and inspection in cases of 127 sanitary instruction in cases of 118-120 sanatorium treatment for cases of 109, 111 spontaneous pneumothorax, in cases of 121 survey 112-113 Tuberculosis nurse 112 collecting sputum specimens 113, 114 county 112 discoverv of cases by 113 duties of 112, 115 house to house canvass by 114 mtmicipal 112 reporting suspected cases to health officer 112,115 survey by 112, 113 visiting reported cases 114 Uncleanliness as factor in spreading disease., 225 Underground water 55 Unrecognized cases of communicable disease, discovery of 19, 98 Unreported births 190 cases of commimicable disease, discovery of 19 duty of health officer re- garding 98 investigation of 20 260 IXDEX Ventilation, efficiency of 228 lack of ' 225 mechanical 230 methods of 227-230 natural 230 Vermin, control of 87-93 of bed bugs 92 body lice 92 head lice 91, 92 itch mites 93 Vincent's angina 141 smear for laboratory examination for 142 Violation of rules affecting public water supplies 35 Visiting homes of venereal disease clinic patients 103 reported communicable disease cases and contacts 94 reported tuberculosis cases 114 Vital statistics, abortions 160 birth certificates 166 comparisons of rates 162 conditions affecting rates 170-171 corrected death rates 164 death certificates 166 death rates 161 estimates of population 161 fatality rates 164 infant mortality rates 165 law in relation to stillbirths 186 relating to reporting of births 186 local registrars 166 marriage as affecting moA-ement of population 162 rates 165 miscarriages 160 morbidity statistics 164 movement of population 162 natural growtli of community 161 necessity for registration of 166 population in relation to ^ 160 practical use of 168-170 rates 162 registration districts 166 specific death rates 163 stillbirths 160, 186 standard population 165 standardized death rate 164 what a nurse should know about 160 Wassermann test 148 Water analysis, laboratory report of 59 carriage systems of sewage disposal 72-73 collection of samples of 58, 62 delffrKiii (if impurities in 54 disease f^'criiis in 53 filtration of 64-65 liard 51 impurities in 52-53 iron in 52 pure 50 quantity of, used in household 51 rain 53-54 safe 54 Index 261 Water — Continued page samples, collection of 58, 62 sanitary analysis of 58 sanitary survey of supply 54 sources of pollution of 54-55 Bupplies 19, 28, 50, 53 inspection of 31 pollution of 56-57 prevention of impurities in 63 surface 54 underground 55 well 55 Waterborne diseases, chemical analysis of 58 investigation of methods of communication of. 50, 53 Watery milk 41 Weighing and measuring children 180 Wells 55 protective construction of 57 surface pollution of 56-57 Widal test for typhoid fever 145 Williams, Dr. Frank E., types of personality developing insanity 220 Wholesome milk 44 Whooping cough 147 vaccine 147 " Working library " for public health nurses 100 Workshop, hygiene of home and 21 I I E 05 26 ^ E>«2^ ^^^ '^^\ •v^- A