UC-NRLF $B bME lfi3 THE ORGANIZATION AND ADMINISTRATION OF THE HEALTH DEPARTMENT OF SPRINGFIELD, MASS. REPORT OF A SURVEY Made by the SPRINGFIELD BUREAU OF MUNICIPAL RESEARCH APRIL, 1914 ■ :y'TiiMm^m^::,::^ji!^a fUSlIC EEiJMH LIB. FRAIIK U KEtlY, Hi. O, FOREWORD THERE is submitted herewith for public consider- ation a report of a detailed survey of the organiza- tion and administration of the Health Depart- ment, pointing out defective conditions obtaining in the department's organization and administration and definite constructive suggestions for the improvement of the efficiency of the operation of this department and of its service to the public. The survey and the report thereon was made for the Mayor and the Springfield Bureau of Municipal Research by Dr. Carl E. jMcCombs of the New York Bureau of Municipal Research. An endeavor has been made to present an honest and impartial report of existing conditions with a view to supporting the Health Department in the progressive steps it has taken, of stimulating citizen and institutional cooperation, and of advancing progressive recommend- ations for increasing the department's efficiency. The report is in no sense meant as a destructive criticism. In every sense and relation it is meant to be constructive. Springfield Bureau of Municipal Research. MS03158 TABLE OF CONTENTS Page Summary of Recommendations 4 Summary of Criticisms 5 Appropriations 8 Appropriations for Health Service Liberal 8 Increased Appropriations for 1914 9 Budget Schedules Not Itemized 10 Too Much Appropriated for Medical Inspectors 11 Revenue 12 Receipts from License Fees, Etc 12 Time Records Important in Determining Charges for Removal of Nuisance 12 Administration 13 Board of Health Unnecessary 13 Division of Authority Hampers Efficient Control 13 Full Time, Adequately Paid, Trained Service Needed 14 Prevention of Transmissible Diseases 15 Reporting of Diseases Dangerous to Public Health 15 More Careful Investigation of Typhoid Cases Needed 15 Need for Investigation of Diphtheria and Scarlet Fever 16 Aids to More Complete Reporting of Disease 16 Registration and Control of Tuberculosis 17 Tuberculosis Register Should Be Revised 17 Placards Should Be Understood by Laymen 18 Quarantine, Disinfection, and Quarantine Release 18 Better Records of Disinfection Needed 18 Laboratory Service a Valuable Aid in Prevention of Disease 19 Laboratory Service Should Be Extended 19 Laboratory Reports Should Not Be Made on Post Cards 20 Protection of the Health of Children 21 Birth and Death Records Important 21 Low Infant Mortality Rate 21 Extension of Child Welfare Service 21 Child Welfare Nurse Recommended 22 Supervision of Midwives Needed 22 Preventive Campaign Needed 23 Supervision of Day Nurseries, Infant Boarding Houses, and Children in Institutions 23 Infant Mortality Charts Would Be Helpful 24 Duties of Medical Inspectors 24 Records of Service Performed Inadequate 24 Time Records Valueless 25 Need for More Thorough Physical Examinations 26 Records of Defects of Teeth Incomplete 26 School Dental Clinic Needed 27 School Medical Clinic 27 Page Visits Should Be Made Daily 28 Duties of School Nurses 28 Nurses Should Render Time Reports 29 Yearly Sanitary Survey of Schools Recommended 29 Salaries of School Physicians Ample 30 Approved Record Forms Recommended 30 Protection of Food Supply 31 Health Department Hampered by State Act 31 Inspector of Meats, Provisions, and Slaughtering 31 Improved Records Needed 32 Inspectors Should Be By Assignment Only 32 Duplication of Work 32 Milk Inspection Service Excellent 33 Minimum Score for Dairies 33 Bacteriological Analysis Shows Improvement of Milk Supply 33 Stores and Restaurants Inspected 34 Spirit of Co-operation Commendable; Dairy Scores Should Be Published . . 35 Cost of Country Milk Inspection Could Be Reduced 35 Records of Milk Laboratory Well Kept 36 Sanitary Inspection 37 Organization of Inspection Service 37 Motor Cycles for Sanitary Inspectors 37 Time Wasted in Transcribing Reports; New Procedure Suggested 37 Inspections Should Be By Assignment 38 Inspectors Should Be Districted 38 Improved Reports Recommended 3S Nurses Should Be Used as Sanitary Inspectors in Summer Months 39 School Children in *' Clean-up " Campaigns 39 Policemen as Sanitary Inspectors 39 Citizens' Complaints Should Be Encouraged 39 Vital Statistics 41 Vital Statistics Not Kept in Health Department 41 Death Certificates Should Be Properly Made Out 41 Cemetery Returns Not Rquired 42 Publicity 43 Publicity — An Agency for Improved Health Control 43 News Articles of Health Interest 43 Weekly or Monthly Bulletins 43 Exhibits, Lectures, Etc 43 Manual Now Being Prepared 44 The Health Department Hospital 45 Hospital Service Commendable 45 Better Accommodations for Nurses Needed 45 Improved Stores Records Should Be Required 46 Use of Private Laundry Dangerous 47 Saving in the Purchase of Milk Probable 47 Cultivation of Land Recommended 48 SUMMARY OF RECOMMENDATIONS 1 — The abolition of the present board of health 2 — The appointment of a single full-time trained health officer who shall be the executive head of the health department 3 — More detailed and accurate information with all supporting data regarding the health department's requests for appropriations 4 — Wider cooperation with physicians, nurses, sanitary officers, police, charity organizations, and others in the registration of cases of disease 5 — More thorough investigation of all cases of diseases dangerous to public health 6 — Revision of the tuberculosis register 7 — More complete and detailed records of disinfection 8 — Improvement of laboratory facilities by the removal of the labora- tory to the municipal building 9 — Extension of laboratory service by improved cooperation with physicians 10 — The appointment of a child welfare nurse 11 — Registration and supervision of midwives 12 — Regular inspection and proper records of day nurseries, infant boarding houses, and other institutions caring for children 13 — The keeping of infant mortality charts showing where work is needed 14 — More thorough physical examinations of school children 15 — Improved records of defective conditions found through a medical inspection of school children and of the efforts made to rem- edy them 16 — Improved facilities for medical and dental care of school children 17 — Daily visits to schools by medical inspectors 18 — Improved records of sanitary conditions in schools and a yearly sanitary survey of each school 19 — Better supervision of the city's food supply 20 — Reorganization of inspection service to prevent duplication of work 21 — The establishment of a minimum score for dairies 22 — More frequent bacteriological examination of milk samples 23 — The establishment of a maximum bacterial standard 24 — Publication of dairy scores and bacterial counts 25 — The provision of motorcycles for the country milk inspector and for sanitary inspectors 26 — The use of the two additional inspectors authorized for 1914 as food and milk inspectors rather than as sanitary inspectors 27 — All inspections to be by definite assignment and based on indi- vidual records of places requiring inspection 28 — Districting of inspectorial staff 29 — Securing the cooperation of nurses, school teachers, and school children in a continuous year round clean-up campaign 30 — Cooperation with police department in using policemen as health inspectors 31 — Requiring the city clerk's office to furnish the health department with copies of all birth and death records — until such time as registration of vital statistics may be placed wholly in the control of the health department 32 — The enforcement of all regulations regarding the reporting of births and deaths 33 — Requiring cemeteries to render reports of all interments 34 — Immediate revision of the sanitary code 35 — Wider publicity of health facts by means of bulletins, lectures, exhibits, and improved annual report SUMMARY OF CRITICISMS 1 — Control of daily health activities and needs by a health board, elected by council without other qualifications than that one member shall be a physician, meeting but twice a month, and without personal contact with and knowledge of health conditions hampers rather than expedites health control 2 — There are at present two health officers — the health physician, who is a member of the board of health, and the health agent who is an executive officer and not a member of the board. Control of various health functions is divided between those two officers each of whom considers himself the head of the department 3 — The health budget estimates for 1914 were not only incorrectly prepared but incomplete in explanation of reasons why cer- tain sums were needed 4 — No attempt has been made to improve registration of diseases by wide publicity and cooperation with both physicians and laymen. It is estimated that there are each year 150 to 200 unreported cases of typhoid fever 5 — Investigation of cases of disease dangerous to public health by a lay sanitary inspector is inadequate for many diseases. There is insufficient study of possible sources of diphtheria, scarlet fever and typhoid fever 6 — The tuberculosis register has not been kept up-to-date, some records dating as far back as 1905 without subsequent entry as to later condition 7 — Disinfection records do not show time spent by inspectors, quan- tities of disinfectant used, room space fumigated, or other action taken although information on these points is essen- tial in determining the efficiency of service 8 — The present quarters of the health laboratory in a private build- ing are poorly arranged, badly lighted and inconveniently equipped 9 — Laboratory reports of examination of specimens are mailed to physicians on post-cards which contain the name of the patient and the laboratory findings. Confidential relations between patient and physician are thus violated 10 — Although the department of health requested a child welfare nurse for 1914 this request was denied by council; The preserva- tion of the health of children demands increased facilities and an effective program 11 — Midwives are unsupervised and unregulated, although statistics show that from 10 to 30 percent of babies are attended at birth by midwives. There are 14 cases of opthalmia neona- torum (a disease causing blindness in babies) and 67 cases of inflamed eyes in 1913 — all such cases are due to improper care of the babies* eyes at birth, either by physician or mid- wife or other attendant 12 — Aside from the inspection required by law before licensure of infant boarding houses or day nurseries the board of health requires no further inspection or supervision 13 — Infant mortality charts showing when infant mortality is highest and when lowest are not kept, although infant mortality is an unfailing index to health needs 14 — Records show that physical examinations of school children are not thoroughly made. Springfield medical inspectors found only 1.2 percent of children with enlarged tonsils, adenoids, and defective breathing, while other cities show that from 10 to 50 percent of school children suffer from such defects. Some Springfield medical inspectors report from 20 to 24 physical examinations per hour 15 — Records of medical inspection of school children and of the nurses* efforts to remedy conditions are inadequate. No figures are given in the department's report for 1913 of the number of children having defective teeth and how such defects were cared for 16 — No facilities are provided for dental care of children or for medical service in treating minor diseases of injuries which are so common among school children and so often neglected 17 — Physicians visit schools only twice each week, although proper control of the health of children requires daily supervision by a physician 18 — No detailed reports of the sanitary conditions of school buildings are made, although physicians are required to report monthly as to whether conditions are " good," " fair," or " bad." Such reports are of little value in determining the sanitary needs of the schools 19 — There is no rule or regulation of the board of health prohibiting the exposure of foods to dust and street filth and this unsan- itary practice may be observed daily 20 — The inspector of meats and provisions, the milk inspector and the sanitary inspectors are in many instances visiting the same place. Duplication of inspection means money and time wasted 21 — The milk regulations do not specify a minimum score for dairies although dairies scoring below fifty should be properly con- sidered as unfit to produce milk for human consumption 22 — Bacteriological examinations of milk samples are infrequently made. Only 702 samples were thus examined in 1913, — an average of one examination a year for each supply 23 — The milk regulations of the board do not fix a maximum bacterial count, and it is therefore possible for milk containing a dan- gerously high number of bacteria to be sold for human con- sumption 24 — Although the citizen may have access to all milk records, no pub- licity is given in the annual report or elsewhere as to the quality of milk sold by the individual dealers 25 — The milk inspector spends about $600 each year for transporta- tion in visiting country dairies. A motorcycle would cost $250 and approximately, one cent a mile for service 26 — Three sanitary inspectors on motorcycles could do as much work or more than six inspectors not so equipped 27 — Two additional sanitary inspectors as authorized for 1914 are not needed. These additional inspectors could be used to better advantage in the inspection of milk and other foods 28 — Inspectors are not sent out on definite assignments based on indi- vidual records of places requiring inspection. Lacking such individual records assignments are either not made, in which case inspection is often of a hit or miss variety, or made and reported on without adequate check as to service performed 29 — Inspectors are not districted, although this is a valuable provision for fixing responsibility and preventing duplication of effort 30 — School nurses are employed in the summer months as aids to the Baby Feeding Association and the Tuberculosis Association. Their work could be made of more value to the health depart- ment by requiring that they keep careful record of all sanitary conditions needing the supervision of the health department 31 — No attempt has been made to organize school children for ser- vice in child welfare work or sanitary control, although other cities have found their aid invaluable 32 — Policemen are not required to report unsanitary conditions or health violations although this is successfully practiced else- where 33 — The city clerk is the registrar of vital statistics and is required only to furnish a daily list of births to the health department. All other records must be copied by the health department clerks. Vital statistics are of value to the health depart- ment in prevention of disease and death, but of no value to the city clerk except for statistical purposes 34 — Deaths are not reported according to the international list of the causes of death, although this is the accepted standard and the one adopted by the Massachusetts state health authorities 35 — Cemeteries do not furnish statements of interments, although such statements would furnish a valuable check on the effi- ciency of death registration 36 — The sanitary code is out of date and of no value as a manual for the instruction of employees and citizens 37 — Publicity is inadequate. Aside from the annual report and occa- sional leaflets relating to health regulations citizens are not informed as to health conditions and health department activities fRANK L. KSLLY, M. D. APPROPRIATIONS Appropriations for Health Service Liberal The health department has been allowed $63,288 for 13 months ending January 1, 1915. This gives a per capita cost of conservation of health of approximately 53 cents on a 12 month basis, which places Springfield well in the forefront of American cities as regards provi- sion for health service. New York City with its extended organization along all lines of health work spent only 57 cents per capita for health conservation in 1912, according to the United States census report. Dayton, Ohio, has recently effected a complete reorganization of its health service, giving the city for the first time in its history a pro- gram and facilities for adequate health protection and education at a per capita cost of 34 cents. The following table, based upon the census report for 1912, shows the comparative cost of health conservation in 15 American cities of 50,000 to 100,000 population: Holyoke, Mass 54c. per capita Somerville, Mass 46c. " " Jacksonville, Fla 46c. " " Savannah, Ga 46c. " " Springfield, Mass 43c. Lynn, Mass 42c. Brockton, Mass 34c. " Sacramento, Cal 32c " Houston, Tex 29c. " Manchester, N. H 27c. " Troy, N. Y 26c. " Waterbury, Conn 25c. " Passaic, N. J 24c. " Elizabeth, N. J 23c. " Schenectady, N. Y 22c. " Springfield is to be congratualted on the liberality of its appropri- tions, but there is no doubt that reorganization of its health service would give more effective control. The problem is not how to reduce health appropriations, for many authorities believe that cities in Spring- field's class (from 50,000 to 100,000 population) should spend at least 85 cents per capita, but so to control expenditures through efficient organi- zation that maximum service may be obtained at minimum cost. a (( Increased Appropriations for 1914 The appropriations for 1914 as compared with the expenditures for 1913 are summarized as follows: 1913 Expended 1914 Requested 1914 Allowed (12 Months) (13 Months) (13 Months) Board of health $14,616.64 $21,813.31 $19,813. Isolation hospital 28,547.54 88,635.00 32,200. Inspection of school children ... 5,702.92 11,275.00 11,275. $48,867.10 *$121,723.31 $63,288. The present budget of $63,288 provides for certain additional services according to the schedule prepared by the health department as follows: Two sanitary inspectors at a maximum salary of $1200 (These inspectors will be appointed later in the year) Inspector of slaughtering (The present inspector of meats and provisions to receive $300 addi- tional salary for this service) Clerk in office of health department at $10 per week Additional nurses at isolation hospital (Number and yearly salary not specified) Ward maid at isolation hospital (Salary not specified) Additional nurse for medical inspection from March 1st, at $65 per month Laboratory helper at $10 per week Provision has been made for salary increases as follows : Health physician from $1500 to $1800 Thirteen medical inspectors up to March 1, 1913 were paid $25 per month for 10 months; they now receive $50 per month for 10 months Budget Schedules Not Itemized Lack of itemization of budget schedules results in inability on the part of the examiner to determine specifically the need for certain requests. It is impossible to discover, except through personal inter- views with health officials, how estimates were made or specifically how appropriations are to be used. Requests for additional service by per- manent employees and temporary employees are lumped together without explanation. The need for more detailed itemization of bud- get schedules is clear. Without such itemization it is impossible for • This amount was increased by requests for $45,000 for an administration build- ing and $10,000 for a smallpox hospital. 10 the mayor or anyone else to determine from the estimate sheets pre- sented by the health department what is needed or why it is needed. For example, " additional nurses " are requested at the isolation hos- pital, but no statement is made as to how many nurses are needed or what salaries they are to be paid. Some of the nurses employed at the isolation hospital receive $600 per year, others receive $480. Again, $2180 is requested for salaries of ward maids at the isolation hospital for 13 months. There are six ward maids at $20 per month, and an additional ward maid is requested at the same monthly rate. Six ward maids at $20 per month for 13 months will cost $1560. One additional ward maid at $20 per month for 13 months will cost $260. The total amount actually specified in the health department's schedule for per- manent service should have been $1820. It is not specified how the remaining $360 is to be used, and although the clerk of the department says this amount is designed to cover extra service which may be required, extra service in 1913 cost but $35. Too Much Appropriated for Medical Inspectors In calculating the amount required for medical inspectors during the coming year, the department based its estimates upon 13 inspectors at $50 per month for the 13 months' period from December 1, 1913 to January 1, 1914, although medical inspectors are employed only 10 months of each year and will be employed only 11 months during the period December 1, 1913 to January 1, 1915. The department requested therefore $8450 for medical inspection service and this was allowed, although only $7,150 should have been requested and allowed as no additional inspectors were asked for or needed. 11 REVENUE Receipts from License Fees, Etc. A small amount of revenue is derived by the city through fees for licenses and payments for services rendered by the health department in removing nuisances. During 1913 the sum turned over to the city by the health department amounted to $395.60, as follows: Licenses for massage and vapor baths (Required by state act at $1 per year) $5 .00 Annual milk licenses (678 at 50 cents) 339 . 00 License to remove dead animals 1 . 00 Payments for removal of nuisances 50 . 60 Total receipts $395.60 Time Records Make Charges for Removal of Nuisances Accurate. The present practice of the health department is to take such steps as may be necessary to remove temporary nuisances when it is impos- sible to compel owners or agents to do so promptly. In such cases the department is empowered to collect the cost of removal from the owner or agent. This is a proper procedure, as it results in the prompt removal of nuisances which otherwise would have to await an action against the owner or agent of the premises. The fixing of costs depends upon the action of the board of health, and the amount is supposed to cover not only the actual cost of removal but also the time required on the part of the sanitary inspectors. Without time records, however, it is im- possible to estimate accurately the proper amount of charge for this service. 12 ADMINISTRATION Board of Health Unnecessary The board of health, which is charged with health administration, consists of three members elected by council for a term of three years, one member being elected each year. Under the ordinance creating the board, it is required that at least one member of the board shall be a physician, who shall be called the health physician. There are no other qualifications for members except that they shall not be members of the city council and that not more than two shall be chosen from one political party. From this last provision it is clear that the framers of the ordinance feared political bias on the part of the board, and the experience of other cities proves that their fears were not groundless. The board meets twice each month or oftener when necessary to decide upon emergency matters. Aside from the physician, who is a member of the board, the selection of the personnel is entirely arbitrary on the part of the council. The other two members may or may not know the city's health needs. If they are laymen they must depend upon the advice of the physician member. A board of health, not thoroughly familiar with modern health movements, dominated perhaps by personal or partisan bias, and meet- ing only infrequently, is not an effective agency for energetic action upon health problems. It is the experience of progressive cities generally that such a board is an antiquated appendage of the local government. It is recommended, therefore, that as soon as practicable the board of health of Springfield be abolished, and that its authority be vested in a single health commissioner or health officer. Division of Authority Hampers Efficient Control Health administration in Springfield is hampered by a division of authority. The member of the board who is a physician is known as the health physician, and if more than one member of the board is a physician, the council elects one as health physician. The duties of the health physician as prescribed by ordinance are " To perform all such medical and sanitary duties as may be required by the board of health and the mayor and the city council. He shall attend the meetings of the board; shall make all bacteriological exami- nations and shall perform such other duties as may be prescribed by ordinance. In case of the prevalence of impending or any infectious or contagious disease within the city, he shall give to the mayor or either board of the city council such professional advice as may be required by any of them." 13 This ordinance seems to imply that the health physician is to act as the chief executive of the health department, but in practice this is not the case. The board of health is given power under the ordinance which creates it to appoint a health agent (now under civil service), and the health agent has become to be in fact the executive head of the health department. The present health agent thus defines his own position: " When the board of health is in session, the health physician is the head of the department. When it is not in session I am the execu- tive head." Full Time, Adequately Paid, Trained Service Needed Springfield needs a full-time trained health officer, with power to act as the direct representative of the mayor or council. He need not be a physician, but he should be thoroughly trained in modern health service. He should have the ability to organize his department effi- ciently; to develop a program for health control along all lines; to anti- cipate health dangers and provide the necessary means to prevent them ; to secure the repeal of hampering legislation wherever necessary; to cooperate with all existing agencies for health service or social better- ment; to carry on a wide-spread campaign for publicity. Such a health officer should be adequately paid not less than $2500 per year, prefer- ably $3000. The state civil service commission should be requested to conduct an examination for a health officer; and the selection of a man for this responsible position should depend not upon his residence in Springfield, or even the state of Massachusetts, but upon his ability to meet the requirements above named. If a Springfield citizen can be found who meets the requirements, well and good ; but Springfield should be satisfied with nothing less than the best when it is within its power to secure the best. The civil service commission has the power to waive all restrictions as to residence, if in its opinion the needs of the public service may so require. An open competitive examination for the position of health officer in the city of Springfield would attract many men of proven ability in health administration. 14 PREVENTION OF TRANSMISSIBLE DISEASES Reporting of Diseases Dangerous to Public Health Those diseases which are specified by the state board of health as ** dangerous to public health " must be reported to the health depart- ment and supervised by it according to the rules of the state board. Prompt and complete reporting of diseases dangerous to public health is imperative if prevention is to be effective. The law states that cases of disease on the specified list of diseases dangerous to public health must be reported immediately, but as the time allowed physicians and others for reporting cases is not specified, there is every reason to believe that all cases are not reported to the board of health. Mortality in many transmissible diseases varies widely, but the mortality in certain dis- eases bears a fairly constant relation to the number of cases. For example, the study of a large number of cases of typhoid fever in cities has fixed the case mortality at 10 to 12 percent of cases. In Springfield during the past year 91 cases and 20 deaths from typhoid fever were reported, giving an exceptionally high case mortality of 24 percent. Calculating the probable number of cases on the average case mortal- ity above stated, there were in Springfield during 1913 from 165 to 200 cases of typhoid fever, only 81* or 40 to 50 percent of which were re- ported to the health department. If we may accept the findings of other investigators as accurate there is evident need for more thorough reporting of this disease at least. More Careful Investigation of Typhoid Cases Needed The 81 cases of typhoid fever reported in 1913 were classified by the health department as follows : ^ 11 cases imported (from other towns) 27 cases — probably out of town infections, were away from the city within 30 days of first symptoms 34 cases — source untraced 8 cases — on one milk route The health department record of typhoid fever cases calls for information regarding the probable source of the disease, but, ciside from the report which is obtained by the sanitary inspector, the records do not show that proper investigation of these cases was made. For ex- ample, the fact that eight cases appeared on the route of one milk dealer is considered by the health department as a coincidence, and accepted * Total number of cases shown in health department's analysis is only 80, al- though the health department's reports show 81 cases during the year. 15 as such. It is an accepted fact, however, that in cities with a uniformly good water supply (such as Springfield has), probably 90 percent of cases are due to infected milk. The department should keep currently tabu- lations which will show the number of cases charged against each milk dealer; and the investiga ion of cases should include a thorough study of possible sources of the disease in milk, both at the producers and at the retailers. Need for Investigation of Diphtheria and Scarlet Fever Although it is well known that milk is frequently responsible for cases of diphtheria, scarlet fever, and tonsilitis, the health department makes little effort to trace the sources of diphtheria and scarlet fever beyond recording the source of the patient's milk supply. Tabulation should be made of all cases of diphtheria and scarlet fever, and each case should be charged against the milk supply of the patient. This does not mean that the particular milk supply is necessarily responsible. If it should be found from this tabulation that a certain dealer has an undue proportion of disease charged against his supply, careful investi- gation should be made to discover the reason and an effort made to prevent further spread of the disease if milk is found to be the source. It is of no value simply to record facts regarding disease unless those facts are used for prevention. Aids to More Complete Reporting of Disease There are probably many other cases of disease " dangerous to public health " which do not come under the observation of a physician. Such cases are not reported, therefore, unless the cooperation of all those likely to come in contact with the disease is secured. Sanitary inspectors in making their rounds of inspection frequently visit homes where there is illness, and they should be required in all cases to ask " Is there any one sick in the house? " In Pittsburgh this is routine procedure, and many cases of disease not otherwise discovered and re- ported are thus brought under health control. School nurses should also be required to report any cases of illness which they may discover in the course of their home visiting. Proprietors of hotels and lodging houses, nurses and social workers connected with private agencies, super- intendents of hospitals and institutions, and all who, by the nature of their work, are likely to come in contact with disease, should be furnished with report blanks and urged to cooperate with the health department in securing complete registration of disease. There are several other measures for improving the reporting of 16 niANK L. KCLLY, M. O. transmissible diseases which should suggest themselves to the health physician or health agent. These may be briefly summarized as follows: 1 — Checking hospital records against register of dis- eases dangerous to public health 2 — Periodic visits to hospitals to discover cases not otherwise reported, particularly tyhpoid fever 3 — Checking death returns in order to discover deaths from diseases dangerous to public health but not previously reported 4 — Wider publicity of health facts Registration and Control of Tuberculosis The control of tuberculosis is at present in the hands of the Tuber- culosis Association, a private agency, although the health department is required to keep a record of cases. A tuberculosis dispensary is main- tained by the Tuberculosis Association under the approval of the state board of health as required by law. Most cities have found that better control of tuberculosis is obtained by placing all responsibility actually upon the health department, which is assumed to be responsible by state and local authorities for registration regardless of what outside agencies may be interested in the work. It is recommended, therefore, that as soon as practicable the department of health take over as much of this work as is practicable with the facilities at hand. A number of anti- tuberculosis societies in other cities have given over to the health de- partment all registration and administrative control, while continuing their outdoor service by visiting nurses. So long as the health depart- ment is required by law to register all cases of tuberculosis there is no need for detailed registration by the Tuberculosis Association, as this means simply duplication. Tuberculosis Register Should Be Revised In the report of the health department for 1913 the statement is found that 95 percent of all cases of tuberculosis are reported to the department. This statement is probably inaccurate. One hundred and twenty-five cases of pulmonary tuberculosis were reported and 73 deaths. Competent authorities have estimated that for every death there are at least five living cases. On this basis the number of living cases in Springfield may be estimated as 365. The register of living cases of tuberculosis, as kept in the health department, contains the records of 485 cases, but as each case is registered on a separate card and as these cards have been very incompletely filled out, the record has little value as at present kept. Many of the 485 cases found in the health depart- 17 ment register were reported as early as 1905, and no subsequent data as to their condition or residence have been supplied. This register should be immediately revised from the records of the Tuberculosis Association. Unless it can be brought up to date and made to serve some useful purpose either in prevention or control of this disease, it is simply a waste of time and money to keep the record. This further emphasizes the need for the entire responsibility of registra- tion, for cooperation between the health department and the Tubercu- losis Association in registration of cases is admittedly not as good as it might be. Placards Should Be Understood by Laymen It is suggested that the placard used in anterior poliomyelitis be changed to read " infantile paralysis," for technical medical terms mean little to the average layman. Quarantine, Disinfection, and Quarantine Release The rules of the state board of health regarding quarantine, disin- fection, and quarantine release are excellent, and so far as can be deter- mined from the statement of the health agent, they are well carried out. The health department in its annual report for 1913 comments upon the fact that disinfection is of doubtful value in many cases formerly con- sidered to require disinfection. The procedure which the health de- partment must follow is however fixed by law, and in view of the present opinion of laymen as to the necessity for disinfection, changes of pro- cedure in Springfield may well wait more definite knowledge on the subject. Better Records of Disinfection Needed If we are to come to any definite or helpful conclusions regarding the comparative value of disinfection procedure, better records are needed. Sanitary inspectors should be required to render detailed re- ports of their service in disinfection. These reports should show the amount and kind of disinfectant used, time spent by the sanitary in- spector, cubic feet of space fumigated, etc. It is of little value to know that the sanitary inspector fumigated 10 rooms unless we know how much material he used, the cubic contents of the rooms disinfected or fumigated, and the amount of time spent. The cost of disinfection is considerable. If the benefit derived from disinfection as now practiced 18 is not an adequate return for money expended, the health department should know it in order that procedure may be changed. The laboratory could be of the greatest service in determining the comparative value of disinfectants or fumigants used. If disinfection is incomplete, it is worthless. Tests should therefore be made to determine accurately whether ordinary room disinfection as now practised really disinfects. Laboratory Service a Valuable Aid in Prevention of Disease In furnishing physicians with facilities for proper diagnosis of disease, in perfecting quarantine regulations, in improving the reporting of disease, and in the analysis of milk and other foods, all extremely important factors in health control, the laboratory is an indispensable part of the city's health service. It is unfortunate that no facilities were provided in the new munici- pal building for laboratory service. The present quarters are alto- gether inadequate, and should be abandoned as soon as possible. Good light, plenty of room, proper plumbing facilities and adequate equip- ment, none of which the laboratory now has, are essential to efficient laboratory service. In the annual report of the health department for 1913 the attention of the municipal group commission was called to the need for providing accommodations for laboratory purposes in the mun- icipal building. As yet this has not been done, but it is recommended that steps be immediately taken to bring it about. The rental of the present quarters will amount to $600 during the coming year. This sum would go far toward providing the needed facilities in the municipal building. Laboratory Service Should Be Extended According to the report of the department for 1913 the bacteriol- ogist made 119 examinations of blood from typhoid patients, examined 299 specimens of sputum of tuberculosis cases, and 1279 diphtheria cultures; a total of 1697 examinations during the year, or a daily aver- age of from five to six examinations. This means either that physicians are not taking advantage of the laboratory as they should, or that the laboratory is not extending its service to the limit. The bacteriological laboratory of the city of Springfield should be rendering ten times as much service to the city. Some of the ways in which the laboratory may further assist in protecting the health of citizens are: 19 Examination of specimens for the detection of venereal disease, including blood tests for syphilis Examination of specimens for the detection of epidemic cerebro spinal meningitis Examination of specimens from eyes of school children, (14 cases of ophthalmia neonatorum and 67 cases of " inflamed eyes " were reported in 1913, but there is no evidence that diagnosis was made by laboratory exami- nations) Provisions of facilities for furnishing typhoid immuniza- tion to those who may wish it Examination of stools for the detection of typhoid carriers Bacteriological and chemical tests of disinfectants and disinfection procedure Research to discover bacterial or other contamination of foods, as exposed bakestuffs, fruits, candies, etc. Research to discover contamination of milk by tubercle bacilli Laboratory Reports Should Not Be Made on Post Cards The laboratory has proved to be of great service in improving the reporting of certain diseases. This service is given free of charge to physicians. Diagnosis of diphtheria, tuberculosis and typhoid fever may be made certain by laboratory examination of specimens. The physician is promptly notified of the result of the laboratory examina- tion, and when specimens are found to be " positive " the health depart- ment is also notified. Physicians are notified of the findings of the lab- oratory on post cards, a different kind of post card being used for each disease. It is recommended that physicians be notified on a form which may be mailed in a sealed envelope, or if post cards are used, that code numbers be used instead of patients' names. There is no reason why the names of patients should be disclosed on post cards; and physi- cians will be more ready to cooperate with the department in reporting disease if they are assured that unnecessary publicity will not be given to the names of their patients. Publicity of health facts is desirable, but this kind of publicity retards cooperation by physicians which is necessary if the laboratory is to be serviceable. A physician will natur- ally hesitate to send a specimen of sputum from his patient with tuber- culosis when he knows that the official notification of his patient's name and the laboratory's findings will be returned on a post card which any one may read. |j||^ It is also recommended that a single notification form be used for all notices to physicians regarding laboratory findings. The cost of printing these forms may be reduced fully one-half in this way. 20 PROTECTION OF THE HEALTH OF CHILDREN Birth and Death Records Important The protection of child health should begin with birth, and in any child welfare campaign, careful study and analysis of birth returns is fundamental. The age of parents, their nationality, the place of birth by wards or in institutions, circumstances attending birth, by whom attended, whether physician or midwife, are all important to the health officer. The meagre information regarding births, which is furnished by the city clerk to health officials in strict accordance with the law, is useless as a basis for effective control of conditions attendant at birth. The same is true of death returns. The health officer should analyze the returns of births and deaths, particularly of infants, and the analysis could not fail to point out where work is needed. Closer cooperation between the city clerk who receives the returns of births and deaths and the health department can be secured with little effort. The fact that the state law prescribes the amount and kind of information which the city clerk must render to the health department is no reason why all the information needed should not be obtained. Low Infant Mortality Rate Springfield is to be congratulated on its low infant mortality rate. Out of 3105 births during 1913, exclusive of still births, there were only 295 deaths during the first year of life. This gives Springfield an infant mortality rate of 95 per 1000 births, — a lower infant mortality rate than any other city of its size in the country of which there is accurate record. Two factors are largely responsible for this low infant mor- tality rate. Springfield has a remarkably good milk supply largely due to the regulations of the health department governing the production and sale of milk and the efficient service of the milk inspectors. The Baby Feeding Association, a private organization, through its visiting nurses, has endeavored to educate mothers in the proper care of their children, in infant feeding, and in the general child welfare program. Extension of Child Welfare Service Protection and preservation of child health is the most fertile of all health fields, and Springfield has unquestionably made a good begin- ning. Several features of an efficient child welfare program have been neglected, although not wholly from failure on the part of the health department to see their need. In the report of the health department for 1913 there is frequent reference to the need for more extended work along this line. Among some of the needs of the Springfield health de- 21 partment in carrying on its campaign for the protection of child health are the following: The appointment of a child welfare nurse Registration and supervision of midwives More adequate supervision of day nurseries, infant board- ing houses, and children in institutions Child Welfare Nurse Recommended The health department requested that funds be appropriated for the service of a child welfare nurse during the coming year. It is to be regretted that this request was not allowed. The child welfare nurse plays a most important role in every adequate health program. In- struction of mothers in the care of themselves during pregnancy and after- wards and of their babies; the investigation of births attended by mid- wives and the supervision of midwives' methods and equipment; in- vestigation of day nurseries, infant boarding houses, and conditions under which children are cared for in institutions; securing cooperation between outside agencies, the pauper department, and the health de- partment; all are essentials of a well organized program. It is recom- mended, therefore, that such a nurse be appointed. In view of the fact that the services of a social nurse have been recommended in the pauper department, it is suggested that for the present at least, the ser- vice required by the health department and that required by the pauper department be performed by the same person, who may be called the " city nurse." As the need for extension of this kind of health and social service is demonstrated, it will doubtless be necessary to employ separate nurses for these two departments. Supervision of Midwives Needed Midwives are entirely unsupervised in Springfield. As no regis- tration of midwives is required, it is impossible to say how many there are in the city. Experience in other cities leads to the belief that at least 10 percent of all babies are attended at birth by midwives. In some cities where there is a large percentage of foreign population, the percentage is much higher. To how great an extent registration and supervision of midwives would reduce infant mortality in Springfield is uncertain. The records of infant mortality and of infant sickness are, however, very suggestive. Fifty-five children died of premature birth and it is more than probable that many of them were attended by mid- wives. Fourteen cases of ophthalmia neonatorum (a specific disease causing blindness in babies) were reported in 1913, and it is also more 22 than probable that a number of those may be directly traced to im- proper care of the babies' eyes at birth. It is the experience of other cities that midwives, unless properly supervised and instructed, com- monly neglect this important duty. The records of the health depart- ment show that, (except for 1913) there has been a steady increase in the number of cases of ophthalmia neonatorum in the past six years. Year Cases Reported 1908 1 1909 7 1910 12 1911 15 1912 18 1913 14 In addition to the 14 cases reported as ophthalmia neonatorum, there were 67 cases of inflamed eyes. The records of the laboratory do not show any examination of eye secretions to determine whether any of these cases were ophthalmia neonatorum. Without adequate labo- ratory examinations, accurate diagnosis is impossible. Preventive Campaign Needed The state board of health furnishes the health department with silver nitrate outfits, which are distributed to physicians and nurses as requested. The proper application of this remedy is a positive preven- tive of the disease. The continued presence of this disease in Springfield indicates lack of adequate preventive measures. Publicity must be widespread, not only among laymen but among physicians and mid- wives. Neglect to observe proper precautions, even among families in the very best circumstances, is often disastrous. Supervision of Institutions for Children A card index was found in which there was a record of 17 lodging houses, four infant boarding houses, and one lying-in hospital (at the almshouse). The board of health requires that these institutions be inspected and approved by the board, but there is no regular reinspec- tion to determine the conditions under which they are operated. The cards give no information regarding infant boarding houses other than their location, the date of their inspection and approval by the board, and the number of children which they are allowed to care for. Of the four infant boarding houses registered one was inspected and approved in April, 1913, one in December, 1913, and two in September, 1913. There is no evidence as to subsequent visits. It is recommended that these institutions be periodically visited at least once each month, and that complete and accurate registration be made of conditions found. 23 Infant Mortality Charts Would Be Helpful Charts should be made showing where infant mortality is highest and where lowest. Such charts would show immediately where work is needed. Just as the health officer finds it valuable to have charts showing the prevalence of contagious disease and pointing out need for special investigation, so charts of infant mortality would point out need for special investigation along definite preventive lines. The report of the department for 1913 shows all these facts, but apparently little use is made of them except as they are used for the annual report. Duties of Medical Inspectors There are thirteen medical inspectors employed by the board pi health at salaries of $50 per month each for a ten-month period. Physi- cians are required to visits schools twice each week at 9.30 a. m., and to devote as much time as may be necessary to the work. The rules state that they shall : 1 — Inspect all children detained by the room teacher or nurse on account of suspected contagious disease 2 — Inspect all children returning to school after an absence beyond two days 3 — Inspect children who are ill and sent to the inspector for diagnosis and advice by the room teacher or nurse. Also reinspection of children previously ordered under treat- ment 4 — Make special daily inspection of children in any school room who have been exposed to diphtheria or scarlet fever by other pupils in the room taken sick with the disease mentioned 5 — Make physical examinations of all children in the public schools each year, assisted by the teacher and the nurse 6 — Make special insjjection of the ventilation and sanitary conditions of school buildings at least once a month Records of Service Performed Inadequate Physicians are required to make weekly reports of their inspections and examinations on special forms, one form being provided for physical examinations, and another for inspection only. On the form which re- quires report of physical examinations, the physician is required to state how much time was spent in making the examination. This is the only time record in use and it has been used only during the present school year. Examinations of these records show that they are improperly made out and inadequately supervised by the health agent or by the board. The following instances show the need for improved reports on the part of medical inspectors and more careful supervision of these reports as they are rendered. 24 One inspector sent in 12 reports, all dated December 2 2d. Each report gave the result of examinations in one school room, and in each case the amount of time spent by the inspector in a room was two and a half hours. It was of course impossible for the inspector to spend two and a half hours in each of 12 rooms on December 2 2d. Another inspector sent in three reports on January 13th, stating that 110 pupils had been examined in three dif- ferent rooms in four and one-half hours, or at the rate of 24 per hour or one every two and one-half minutes, — a physical impossibility if thorough examinations are made Still another inspector sent in three reports dated Febru- ary sixth, and in the three rooms visited spent six and three-quarters hours in physical examination, — in all probability an incorrect statement, as the school day is not six and three-quarters hours long In one instance an inspector reported that on December 17th he visited two rooms and examined 75 pupils in six and one-half hours In another instance an inspector reported that he made in one week 325 physical examinations in 15^ hours or at the rate of 22 examinations per hour Notwithstanding the fact that teachers make examinations of eyes and ears, it is to be doubted whether any physician can make 22 to 24 thorough physical examinations in an hour. The best authorities place 6 to 10 examinations per hour as the limit of efficiency. In the cir- cular of instructions issued by the health department the statement appears, " The room teacher and nurse are expected to assist the inspec- tor in such measures as may be necessary for the early completion of the work. With such assistance, 10 to 12 pupils can be examined hourly." Time Records Valueless It was evidently intended that the records of physical examination should show accurately the time spent by physicians in making physical examinations. If they had been kept accurately, they would un- doubtedly have furnished valuable evidence as to the efficiency of in- spectors and their work. As now kept they are worthless. Inspectors evidently thought that the dates required by the reports were the dates on which they were sent to the department, although the record form states " This blank is to be made up from individual records and returned to the office promptly on completion of the examination of pupils in each room, i.e. with weekly reports." If the record does not give the date on which the examinations were made, no information as to the actual amount of time spent on any one day in physical examina- tions is available. 25 Need for More Thorough Physical Examinations According to the reports of the inspectors, out of a total of 13,589 examinations made by medical inspectors in the schools, only 106 cases of chronic hypertrophied tonsils, 42 cases of adenoids, and 14 cases of defective breathing were discovered. This gives a total of 162 cases of hypertrophied tonsils, adenoids, and defective breathing, or approx- imately 1.2 percent of all pupils examined. Either the percentage of defects of this kind is remarkably low or examinations are not carefully made. A comparison of like findings in other cities shows that the percentage of cases of adenoids, tonsils, and defective breathing varies widely from as high as 20 to 25 percent among children in lower grades to from 5 to 10 percent among children in higher grades. In a cooperative study made by the bureau of child hygiene of the New York health department and the Bureau of Municipal Research, it was found that 1442 children in three New York schools showed the following percentage of physical defects due to hypertrophied tonsils and defective nasal breathing: Defective nasal breathing 59 percent Hypertrophied tonsils 39 percent On the basis of a 40 week school year, two days per week, 13 physi- cians examining 13,589 children would be required to examine about 13 children at each school visit. In view of the fact that under the state law examinations for sight and hearing are made by teachers, the thor- ough examination of 13 children should not require much more than one hour. There is therefore no reason why any physician should find it necessary to make as many as 22 examinations per hour. Properly distributed, physical examinations could be easily made during the year. It is therefore unnecessary that the physicians should work at such a rapid rate for only part of the year. Physical examinations made less rapidly would probably be made more efficiently. Records of Defects of Teeth Incomplete In the report for 1913 no figures are given as to the number of cases of defective teeth found, although in the report for the preceding year the discovery of 555 cases of defective teeth was reported. The remedying of defective conditions of teeth is one of the most important functions of medical inspection, and many cities have established free dental clinics for this purpose. It is recommended that the same pro- cedure be followed in caring for defective teeth as in other defects, and that records be kept which will show whether defects of teeth are being 26 remedied. Nurses should make home visits when necessary to give dental treatment, and the results of their work should be as clearly stated as the results of home visits for other purposes. School Dental Clinic Needed The school dental clinic has proved to be a most effective part of the medical inspection service. A school dental clinic may be equipped at an initial cost of $300 to $400. Without it, the remedying of defects of teeth is not easily obtained. It is probable that a dentist could be secured at a small salary to give one or two mornings per week to this work. The city of Hoboken has found the dental clinic to be a most satisfactory aid in improving the health of its school children; in fact, the benefit derived has been so great that Hoboken has employed a school dentist at $1500 a year to conduct dental clinics five days a week, and it is not uncommon to see 25 or 30 children at the clinic waiting to be treated. New York City has a well developed dental clinic system, and Dr. Josephine S. Baker, director of the bureau of child hygiene of the New York health department, regards the dental clinics as indispensable. Approximately 75 to 80 percent of school children have defective teeth. Springfield should consider the advisability of providing a dental clinic during the coming year. School Medical Clinic The school medical clinic is also an advanced step in health control. Hoboken's medical clinic also may be mentioned here as a particularly excellent one. The initial cost of equipping this medical clinic, which is in the high school building, was approximately $1000. Hoboken be- lieves that this was money well spent, for many defects of children which otherwise might go unattended are promptly taken care of in the school clinic. The establishment of a school clinic may also be offered as a suggestion for improving Springfield's health service. The object of medical inspection and supervision is not merely to find physical de- fects, but also to see that these defects are treated. The loss of time by pupils on account of physical defects which prevent them from striking a normal pace in school work, the loss of time by teachers in trying to hurry along those who are backward by reason of physical disability, the loss to the individual in health and the consequent cost to the com- munity are factors which should be considered in determining whether the city can afford the expense of these improvements in medical in- spection. 27 Visits Should Be Made Daily For the detection of contagious diseases and improved supervision of the welfare of children, it is recommended that inspectors make school visits daily instead of twice a week. Two hours a day for five days a week in medical inspection would mean approximately 40 hours a month. At this rate the physician would be paid at the rate of $1.25 per hour or $8.75 per day of seven hours. This would mean a probable increase of four hours a week in service. Duties of School Nurses Two nurses are employed at $65 per month each, and provision has been made for an additional nurse at a like salary. The instructions to nurses state that they are required to make visits to the homes of chil- dren: 1 — Who have been excluded from school 2 — Who are not receiving requested treatment for para- sitic conditions 3 — Without medical care who should receive such atten- tion, but only after notification of the need for treatment has been sent to the parents 4 — Having eye, ear, or throat conditions which are neg- lected by parents According to the report of medical inspectors for 1913, cases were referred to nurses as follows: Skin diseases 116 Parasitic affections 107 Enlarged tonsils and adenoids 137 Defective eyesight 100 Miscellaneous 94 Total 554 Out of the total 554 cases referred to nurses, 446 or 80 percent were reported as "relieved." Fifty-eight percent of 100 cases having defective eyesight were fitted with glasses, and 31 or 22 percent of 137 cases of enlarged tonsils and adenoids were cured by operation. This is a praise- worthy record so far as treatment is concerned. In all, the nurses made only 1199 home visits. On the basis of a 200-day school year, they aver- aged only three home visits per day. The nurses' most valuable ser- vice in the program of medical supervision is in home visiting. In view of the amount of work which physicians found for nurses to do according to the records of 1913, it is not clear why an additional nurse should 28 "««« I. wiir. m. o. have been deemed necessary. One visiting nurse, according to the ex- perience of other cities, should be able to make at least four home visits per hour, provided she arranges her home visits properly. In view of these facts it is believed that more home visits should be made by nurses. There are probably many more cases than those referred to nurses, according to the record, which need the nurses' attention and more thorough examinations on the part of the physicians may demonstrate the need for an increased number of nurses. Nurses Should Render Time Reports According to the instructions of the department as printed in cir- cular form, nurses are required to make daily records of work performed, and weekly reports are to be sent to the health department. This pro- cedure is not followed. Monthly reports only are rendered, and these give merely a summary of cases referred to the nurse and action taken upon them. It is recommended that nurses be required to render daily reports of service with a statement of the time spent in each line of duty. Experience in examining the work of school nurses in other cities dem- onstrates that little attention is paid to the arrangement of schedules for home visits with the idea of saving time and increasing efficiency. Daily reports of nurses showing how time was spent in schools, where visits were made, and the time required to make them, would be invalu- able in determining how far the nursing staff is able to cope with the work and whether added service is needed. Yearly Sanitary Survey of Schools Recommended The weekly reports of inspections call for information as to the condition of sanitaries and the adequacy of ventilation. This informa- tion is regularly furnished each month as required, but as the reports require the inspector to state merely whether conditions are good, fair, or bad, they convey little information as to conditions actually exist- ing. Springfield has reason to feel proud of its schools. It is therefore incumbent upon the community to give proper attention to school sani- tation. It is recommended that in addition to the monthly inspection of sanitaries and of ventilation physicians make an annual survey of sanitary conditions of the schools under their charge and furnish a com- plete and detailed report of the matter to the school department, with recommendations regarding lighting, ventilation, cleaning of floors, toilets, drinking and washing facilities, cloak rooms, fire protection, etc. Such a report would be of the greatest value to the school com- mittee in bringing all school buildings up to proper sanitary standards. 29 Surveys should then be made at the close of each school year in order that necessary improvements may be made before the beginning of the next school year. Salaries of School Physicians Ample The city of Springfield pays medical inspectors at the rate of $50 per month for 10 months' service. As physicians are not required to furnish records of service performed, except as to the time spent in making physical examinations, it is impossible to say how much time was really spent by inspectors in school service. From a study of such records as are available, it is estimated that inspectors average about two and one-half hours to three hours per day of five to six hours per week. On this basis they receive $2 to $2.50 per hour or at the rate of $14 to $17.50 per day of seven hours. This is a very ample provision. The fact that officials who are responsible for requesting and granting sal- aries and salary increases do not have this information, makes it impos- sible for them to determine whether salaries or salary increases are proper. Approved Record Forms Recommended Both physicians and nurses should be required to render daily reports of service rendered and time spent on duty. Instead of two separate weekly reports of inspections made and physical examinations given, one report of all work performed, rendered after each school visit, should suffice. This would simplify reporting and reduce printing cost. The physical record card of the pupil which is kept in the school by the teacher should be revised so as to show not only physical examinations made but inspections, illness from contagious disease or other diseases, first aid given, results of nurses, efforts to secure treatment, and in short all that takes place with reference to the child's health. It would com- bine in one record all the information given on several records and fur- nish a valuable guide to physician, nurse, and teacher. Cards for this purpose have been devised by Dr. Louis W. Rapeer of the teachers' training school of New York University, and may be taken as a sample of a record which may be revised to suit the particular needs of any city. Anything which may be done to reduce the amount of clerical work required of physicians, nurses, and teachers should commend itself to any one with experience in medical inspection. 30 PROTECTION OF FOOD SUPPLY Health Department Hampered by State Act The health department is hampered in its efforts to control the pro- duction and sale of foods by a state law which reads: " Boards of health of cities and towns may make and enforce reasonable rules and regula- tions, subject to the approval of the state board of health, as to the conditions under which all articles of food may be kept for sale or ex- posed for sale in order to prevent contamination thereof and injury to the public health. Before the board of health of any city or town sub- mits such rules and regulations to the state board of health for approval it shall hold a public hearing thereon, of which notice shall be given by publication for two successive weeks, the first publication to be at least two weeks prior to the date of the hearing, in a newspaper published in the county in which such city or town is located. Any person affected by such rules and regulations in the form in which they are presented to the state board of health for approval, may appeal to the said board for a further hearing and said board shall not grant its approval to rules and regulations concerning which such appeal has been taken until it has held a public hearing thereon, advertised in the manner specified above in this section with reference to hearings before boards of health in cities and towns." The result of this act is to make it extremely difficult for local boards of health to pass regulations to protect the food supply. In few states is the right of the local boards of health to protect the health of its citizens hampered in this way, and yet it is rare indeed that the individual affected by the regulations is injured. It is evident, however, that the local health department can make regulations even though the sanction of the state board is necessary and the amount of red tape which must be unwound is considerable. The board of health has shown too great reluctance to make such regulations except those governing sanitation in bakeries and the production and sale of milk. Inspector of Meats, Provisions, and Slaughtering The inspector of meats, provisions, and slaughtering visits the vari- ous food establishments and inspects food products according to the laws which the state has laid down regarding the methods of handling and selling food. These laws are intended to be supplemented by local regulations, but except for regulations governing bakeries and the pro- duction and handling of milk, the board of health has paid little atten- tion to food control. 31 The report of the inspector of meats, provisions, and slaughtering shows that 9662 wholesale and retail stores of all kinds were inspected in 1913. This record is a quantity record only. No records are kept which will show the location of the places inspected, what conditions were found, what improvements recommended, what improvements were made, or how much time was actually spent on duty. It is absurd to send an inspector out on hit-or-miss inspection of this kind without any check whatever upon his work, except a summary of places visited. Improved Records Needed Files should be kept in which each store or business inspected may be separately registered on a card. This card should contain all the information required regarding the sanitary conditions of the store, character of food sold, findings of inspector, condemnation, prosecu- tion, etc. A special tickler file should be kept of stores which require frequent inspection. It would not be necessary for the inspector to visit every store in the city regularly, because there are certain stores which do not require regular or routine inspection, but those stores which are in need of inspection should receive it regularly. Inspections Should Be Assigned The health agent or chief inspector should make out each day's assignments of inspections to be performed, and the report of the inspec- tors which should be rendered daily should show clearly that the assign- ment was properly performed. Duplication of Work The reports of the inspector or meats, provisions, and slaughtering show that he visited 3168 retail groceries in 1913, many of which doubt- less sold milk. The sanitary inspectors' reports show that they visited 455 bakeries, 34 restaurants, and 57 stores, many of which must have sold milk. The records of the milk inspector show that he inspected 1042 stores and restaurants, visiting in all probability many of the stores and restaurants which were also visited by both the inspector of meats, provisions, and slaughtering and the sanitary inspectors. This means that in many instances three inspectors visited the same place to obtain three different kinds of information. One inspector should have been able to get all the information required by himself and by the other two inspectors, and to collect what samples might have been needed by the laboratory. The milk analyst, who is already over- crowded with work in his laboratory, should not be required to go out inspecting stores and collecting milk samples. 32 When the food inspector visits the store, he should make the san- itary inspection required so that it will not be necessary for another kind of inspector to come immediately after him. If milk is sold in the store he should make the sanitary inspection of facilities for handling milk, and take a sample according to the instructions of the milk inspec- tor. The inspection of that store would then be complete. There is no reason why sanitary inspectors should be required to visit food stores. One of the sanitary inspectors, preferably one who is to be newly ap- pointed, should be assigned to food inspection under the direction of the inspector of meats, provisions, and slaughtering. If necessary, still another sanitary inspector should be assigned to food inspection. This would give a much better balanced service, and prevent duplication, for food inspectors would make in each store visited a complete survey of all conditions of food and sanitation and would take whatever samples might be needed by the milk analyst. Milk Inspection Service Excellent Springfield is to be congratulated on the efficiency of its milk in- spection service. There are 613 dairies nearby sending milk into Spring- field, and during the past year the milk inspector and his assistant made 1002 inspections. Almost every dairy received at least two inspections. Dairies are scored by the use of the score card advocated by the federal government. The milk inspector states that the scoring of dairies coupled with bacteriological analysis of milk has been of the greatest service in raising milk standards. Minimum Score For Dairies The milk inspector states that the majority of dairies score between 60 and 70, but that some are below 50. He says also that he believes that milk regulations should require a minimum score of 50, and that milk from dairies scoring below this point should be prohibited. Such a minimum requirement is valuable in affording a basis for legal action, should such action be necessary. Bacteriological Analysis Shows Improvement of Milk Supply Bacteriological examinations are at present made the year round. During 1913 specimens of milk from various producers were analyzed bacteriologically with the following results: 260 or 37.1 per cent 10,000 and under 84 or 11.9 102 or 14.5 58 or 8.3 55 or 7.8 54 or 7.7 89 or 12.7 Between 10,000 and 20,000 20,000 and 50,000 50,000 and 100,000 100,000 and 200,000 200,000 and 500,000 500,000 and over 33 Comparison of results of bacteriological analyses during 1911 and 1912 with those of 1913 shows clearly a marked increase in samples show- ing low bacteria count and a decrease of those giving high counts. This indicates that the bacterial standard is constantly improving through careful scoring of dairies. The milk inspector states that he believes that the city should adopt as a part of the milk regulation a maximum bacterial count of 500,000. He believes that such maximum bacterial standard would be useful as a check upon the sale of contaminated milk. As the regulations now stand, no mention is made of bacterial con- tamination. As an indication of improper production and handling of milk, bacterial counts are valuable, and the milk which is persistently high in bacterial content is justly the object of suspicion. Evidence of contamination on the ground of a high bacterial content, however, would not, under present regulations, be ground for prosecution by the department. According to the above figures only 702 samples of milk were exam- ined bacteriologically, or an average of one bacteriological examination per year for each supply. This number should be substantially increased during the coming year, particularly during the summer months when bacterial contamination is more likely and the danger of milk infection greatest. Since dairies can be visited with the present force only about once in six months, the indication given by bacterial count would be helpful in giving an index to the condition of production at a dairy during the interval between dairy inspections. The appointment of a labora- tory helper, recently authorized, will free the milk inspector from much of the routine laboratory work which is necessary. If possible, the laboratory helper should be one who may be taught something of the procedure necessary in making routine determinations, so that the milk inspector will be able to devote a greater part of the time to the determi- nations which require his technical skill. Routine laboratory procedure does not require a great deal of technical training, and much of the lab- oratory work done in large city departments is done by comparatively untrained assistants. Stores and Restaurants Inspected The milk inspector and his assistant made in addition to the 1002 dairy inspections mentioned, 1042 inspections of stores and restaurants selling milk, and 838 inspections of milk wagons. Samples to the num- ber of 2710 were collected from these various sources and analyzed chemically. Of these, the laboratory reports that 547 or 20 percent were found to be below the standard set by the state. Prosecutions were only brought against those persons whose samples showed added water. There were four such cases and four convictions were obtained. 34 When the milk inspector finds milk below standard according to chemical analysis, a notice is sent to the producer of the laboratory findings together with a statement of the legal standard required. The milk inspector states that he has found dairymen willing to cooperate with the department in improving standards, and that where they have shown willingness to cooperate, no prosecution has been ordered. Spirit of Cooperation Commendable; Should Publish Scores The milk inspector is to be commended for his efforts to secure the cooperation of dairymen and citizens. He states that dairymen are eager to learn what the analysis of their milk shows. The milk inspector sends out as routine a statement to the producer informing him of the condition of his milk as shown by analysis. A list is kept in the office of the department which shows which dealers are selling the cleanest and best milk, and we are informed that physicians and citizens make good use of the list. The milk analyst stated that he had during the past year about a thousand requests from citizens regarding the quality of milk purchased by them. As a further step in publicity it is recommended that the depart- ment publish dairy scores and bacterial counts in the newspapers. In- forming citizens of the condition of their milk supplies is one of the most effective ways of raising the standard. There are certain difficulties in the way of further improving the milk supply of the city. As soon as dairymen discover that they are producing a better product, they refuse to sell to wholesalers except at a higher price. Wholesalers refuse to add to the wholesale price, be- cause they may buy their milk from dealers farther away without appre- ciable increased cost of shipping. The result is that wholesalers are con- stantly changing their supply, and producers who have been brought up to a high standard by the local inspectors take their milk to other markets. The only remedy available in this case is so to educate the public that it will demand the best and be willing to pay for it — and the public can only be educated through wide and constant publicity. Cost of Country Milk Inspection Could Be Reduced The laboratory has been allowed $600 for transportation during the coming year. This is chiefly spent by the assistant milk inspector in visiting dairies. The present incumbent is a man of 66 years, who is giving good service according to the statements of the milk inspector. For this service he receives $1400 per year. It is recommended that a younger man be employed. A graduate of an agricultural school, familiar with modern dairy methods and dairy scoring, could be secured 35 for $1200 as an initial salary. The purchase of a motor cycle for use by the country milk inspector would reduce the cost of transportation fully 50 percent, — a saving of about $300, and the inspector would be able to cover much more ground than at present. Records of Milk Laboratory Well Kept The records of milk inspection are very carefully kept and com- plete in detail. A daily record is kept of all milk examinations per- formed and of the findings in each case. A special card index is kept of stores, restaurants, and bakeries selling milk. This record requires information as to the condition of rooms, refrigerators, and milk tanks, and facts as to temperature at which milk is kept. The milk inspector and his assistant are required to render weekly reports of service per- formed. It is suggested that these weekly reports include informa- tion as to time spent in service. This is particularly important in deter- mining the efficiency of the inspector who visits and scores dairies. It has been the experience of other cities that field inspectors should be given as thorough supervision as possible through complete and detailed reports of time and service. 36 SANITARY INSPECTION Organization of Inspection Service There are four sanitary inspectors: one chief inspector at $1400; two at $1200, and one at $1050. Their duties are of a general nature, the inspection and abatement of nuisances, the investigation of com- plaints, special investigations of contagious diseases, the disinfection of premises following quarantine, and such other duties as may be required. Two additional inspectors at maximum salaries of $1200 each have been allowed the health department for the coming year. It is recommended that they be selected with a view to other service as well. At least one of the inspectors should be selected with the view to making him an assistant to the inspector of meats and provisions. The other might profitably be detailed as city milk inspector under the direction and instructions of the chief milk inspector. This would relieve the sani- tary inspection force of the responsibility of inspecting food stores of any kind, and give the department a better balanced inspection force. Motor Cycles for Sanitary Inspectors Sanitary inspection requires that inspectors cover a great deal of territory during the day. Street car tickets are furnished as needed. The health department estimated that transportations for sanitary in- spectors and an additional nurse during the coming year would amount to $250. Many cities have found that time and therefore money can be saved by the provision of motor cycles for the use of sanitary in- spectors. Two sanitary inspectors equipped with motor cycles could cover as much ground as four inspectors not so equipped. Provided machines are given proper care, the upkeep is negligible, and the initial cost when distributed over the life of the machine (three or four years) would be saved many times over in time and improved service. Time Wasted in Transcribing Reports; New Procedure Suggested Sanitary inspectors are required to render daily reports of inspec- tions. During 1913 sanitary inspectors made 21,238 inspections and fumigated 1139 rooms, besides spending considerable time writing reports. It is suggested that when the records of sanitary inspection which the department wishes to keep have been determined, the inspectors be given an assortment of those forms in a protecting cover, and that they make their entries in the field instead of using valuable time in copying field memoranda into a permanent record. One writing should suffice 37 just as the milk inspector makes only one writing in scoring a dairy. , Provided the right kind of record forms are used, all the information needed could be made a matter of record at once. Inspections Should Be by Assignment As a special file is now kept of bakeries under sanitary inspection, so special files should be kept of all other places requiring sanitary in- spection. In addition to the sanitary inspection of bakeries, which is required by law, inspection is made also of barber shops, lodging houses, restaurants, stables, theatres, etc. Special files are kept of sanitary inspection of dairies, stables, and lodging houses, but separate files should also be kept of all other places under inspection, each place having its own individual card. Cards should show the exact conditions found, improvements recommended, action taken, prosecution, etc. It would then be possible to inaugurate a campaign of sanitary inspection instead of following the present hit-or-miss methods. No inspector should be sent out without definite assignment; and it should be the duty of the chief inspector to prepare definite assignments from the files of places requiring inspection. The chief inspector states that no inspector is sent out without definite assignment, but as there is no record of these assignments, it is impossible to tell whether or not work is carried on accordingly. Under the present plan a lodging house, restaurant, or theatre may be inspected but once a year. Not all such places require frequent inspection, but many places do require inspection weekly or monthly. A tickler file should be kept of places requiring frequent in- spection. Inspectors Should Be Districted As part of the plan for improved sanitary inspection, inspectors should be assigned to definite districts. They should not remain in the same district indefinitely, but should be shifted from time to time in order that familiarity with persons or places may not render them indif- ferent to conditions. Improved Reports Recommended Experience in estimating the work of food and sanitary inspectors proves that adequate records of service performed are absolutely essen- tial to proper supervision of their work. Reports should be rendered daily and they should show where the inspector went, what he did, and what time was required. On this basis alone can a supervising officer determine the needs of his department. Without the supporting facts which such reports would give, no one can determine properly whether 38 more men or fewer men are needed. Quantity of work performed is no index to efficiency, as work may have been carelessly done. The record of 21,238 inspections by sanitary inspectors in 1913 indicates nothing, as 16,119 of these inspections were of yards. The inspection of a yard might require ten seconds, while the inspection of a theatre might re- quire half an hour or more. Nurses Should Be Used as Sanitary Inspectors in Summer Months There are two visiting school nurses at present, and one additional nurse will be appointed later. These nurses are required to give year round service. Work among school children is practically at a stand- still during the summer months when sanitary conditions are usually worse. It is recommended that these nurses be used for inspection study in addition to their work for the Baby Feeding Association. Housing conditions in Springfield were carefully studied in 1912 by the Bureau of Social Research of New England under the auspices of the Housing Committee of the Union Relief Association, and the report indicates many ways in which the health department may be of service in remedy- ing conditions. A similar survey during the summer months by the nurses of the health department and the keeping of proper records of their work, would doubtless prove of greatest value to the department in its program for sanitary inspection. School Children in *^ Clean-up '* Campaigns New York City has found that school children may be organized and effectively used in sanitary inspection and " clean-up " campaigns. The cooperation of school teachers, physicians, nurses, and children should be sought in the work of a continuous year round " clean-up " campaign. Policemen as Sanitary Inspectors There are approximately 150 policemen in the city, — a force which could be effectively used in enforcing health regulations. Policemen, if they are wide awake, see many conditions which need health supervi- sion. They should be instructed in the more common regulations of the health department regarding the control of disease, food inspection, and sanitary inspection, and required to report violations of sanitary regulations to the health department. Citizens' Complaints Should Be Encouraged Complaints are received by the health department and, according to the records, promptly investigated. Record is kept of all investiga- tions and reinspections on a permanent record filed in the health de- 39 partment office. Citizens' complaints are very effective in showing what is wrong in the city, and the leads which such complaints sometimes open up frequently result in the inauguration of more effective measures for control. The experiment has been tried by a private organization in New York of placing pads of blank post card complaint forms in pub- lic places where citizens may make use of them as needed. The result has been that many health abuses have been discovered by citizens and through their complaints have been remedied by the proper officials. Citizens should be encouraged to complain to the health department. The method practised in New York could be adopted to advantage by Springfield, not only in the health department but in all city depart- ments. As an experiment, it is recommended that the health depart- ment prepare blank post card forms which may be distributed through- out the public buildings of the city, in clubs, and in office buildings. 40 FRANK L. KCLLY* M. O. VITAL STATISTICS Vital Statistics Not Kept in Health Department Vital statistics are kept by the city clerk according to law. This means that the information which should be constantly available to the health authorities regarding births and deaths is filed in an office which makes little use of them except for publication in the annual report. The health department receives a brief statement of births from the city clerk daily, giving the date of birth, sex, color, family name, resi- dence, and physician or midwife's name. The procedure is fixed by law, even to the form of the report which the health department receives. Information as to deaths is obtained by the health department only by copying the death records in the city clerk's office. This the health department does on its own initiative, as the city clerk is not required to furnish copies of the records to the health officials. It is hoped that the registration of vital statistics, upon which all health work must be based, will be placed in the hands of the health department where it rightfully belongs. Repeal of the state act is necessary but even state laws may be repealed when legislators can be convinced that improve- ments may be effected thereby. Death Certificates Should Be Properly Made Out Examination of copies of death returns in the health department indicates clearly the need for more adequate supervision of these rec- ords. The causes of death are supposed to be entered in the death return according to the international list of the causes of death, in order that these may be a basis for classifying deaths properly. Unless there is someone who is familiar with the proper method of making out death returns to supervise these records as they are sent in by physicians, returns will always be inadequate and incomplete. For example, the following unsanctioned causes of death were found on examination of one month's returns. Pulmonary paralysis Hemorrhage from the lungs, natural cause Meningitis Gastro-intestinal indigestion Inanition Cardiac dyspnoea " Pulmonary paralysis " means absolutely nothing as a cause of death. It does not serve to show whether death is due to any one of the several diseases which may have produced the so-called " pulmonary paralysis." " Hemorrhage from the lungs, natural cause " gives no 41 information as to what caused the hemorrhage. Certainly it was not " natural." The individual may have had pulmonary tuberculosis, organic disease of the heart, aneurism, or one of a number of conditions. " Meningitis " may have been tuberculous in origin or it may have been epidemic cerebro spinal meningitis, facts important for a health officer to know. " Gastro intestinal indigestion " may mean several things, but it cannot be classified according to the authorized list of causes of death. " Inanition " means nothing except to the one who made the record. " Cardiac dyspnoea '* is a symptom and not a cause of death. Such returns properly checked by the officer receiving them should have been returned to physicians for correction, but they were not. Physicians should be supplied with the international list of the causes of death and urged to fill out their death returns accordingly. Otherwise, statistical tables of the causes of death as arranged in the reports of the health department are of very limited value. Cemetery Returns Not Required In checking certificates of death to secure accuracy and complete- ness of registration, reports of bodies interred in the various cemeteries throughout the city would be extremely valuable. Cemeteries are not required to render such reports to the health department. It is rec- ommended that the health department require that cemetery officials render monthly reports of bodies interred in cemeteries under their charge. 42 PUBLICITY Publicity — An Agency for Improved Health Control Publicity of health facts is one of the most powerful agencies in improving health control. Much has been done by the health depart- ment in preparing educational leaflets regarding the prevention of con- tagious diseases and the protection of food supply. There is still much to be done along this line. News Articles of Health Interest Springfield has good newspapers with extensive circulation through- out the city and state. Articles from Springfield papers are copied by other cities all over the country. Timely and interesting articles should be prepared for them by health officials regarding the prevalence of dis- ease, method of prevention, sanitary conditions throughout the city, protection of food supply, medical inspection of school children and the perservation of child health, fly dangers and how to avoid them, and many other topics of interest to citizens. Such articles would aid in securing better cooperation on the part of the citizens and inform them of the purposes and needs of the health department. Few people read the formal reports of the health department but there are few who do not read the newspapers. Weekly or Monthly Bulletins The health department should issue weekly or monthly bulletins giving the facts regarding the prevalence of disease, the work of the de- partment, and articles on public health in general, such as the protection of milk supply, the prevention of typhoid fever, vaccination, etc. Wide- awake health officers all over the country are finding such bulletins of the greatest service. They should not be distributed among other health officers but used for the information of Springfield citizens. They should be sent into homes, and placed in libraries, reading rooms, etc., wherever they may catch the eye. Health interest can be developed beyond mere pride in a low death rate and every effort should be made to develop it. Exhibitis, Lectures, Etc. The recent experience of Springfield with its municipal exhibit proved conclusively that citizens are interested in city government when facts are interestingly placed before them. Health exhibits are invari- ably the most interesting of all municipal exhibits and facts regarding health conditions may be brought out better in this way than by any 43 other method. It is recommended that the health department use the material which it has for the establishment of a permanent exhibit for use in schools, churches, and other organizations interested in health. Lectures to school children, teachers, trades unions, civic societies, and other bodies have been found to be particularly useful in the pro- motion of health service. There are without doubt many physicians of the health department who would be glad to prepare and deliver such addresses provided the opportunity were given them by the health department. Manual Now Being Prepared A new health manual is now being prepared by the health depart- ment. This manual should be kept to date yearly. It should be de- signed to inform inspectors, citizens and others as to the duties of the department and how the law requires these duties to be carried out. U THE HEALTH DEPARTMENT HOSPITAL Hospital Service Commendable The health department hospital is in charge of the health physi- cian. The buildings which are situated adjacent to the almshouse are two in number, one building for contagious diseases accommodating 30 to 40 patients, and the other for tuberculosis accommodating about 25 patients. So far as can be determined under present conditions of occu- pancy, these two buildings are ample. There were at the time of inves- tigation but 15 cases of tuberculosis in the tuberculosis wards and 31 patients in the contagious disease wards. The buildings have been remodeled during the past few years and at present arrangements for caring for patients are satisfactory. Ac- cording to the statement of the health physician, no mixed infection has occurred in the contagious wards since the service was begun. Rooms for the different contagious diseases are entirely separate and every care is taken to prevent cross infection. Facilities for the disposal of waste are excellent, two small incin- erators having been installed in which not only infected waste material from the wards but also kitchen garbage is consumed. The buildings when visited were found to be in excellent condition throughout and there was every indication that no efforts were spared to keep the buildings and equipment clean and orderly. On account of the limited study made and of the fact that the hospitals were operating at one-half of their capacity, it is impossible to say whether the care given patients is adequate. There are seven nurses six ward maids, and one orderly on duty in the two hospitals. This number would seem to be ample for present needs. Medical attention is furnished by local physicians free of charge; four being assigned to contagious disease service and three to tubercu- losis service. In addition, special service is rendered to the two hospitals by a specialist in diseases of the ear and throat. Physicians alternate in visiting attendance every three months and the health physician states that their service is satisfactory. Better Accommodations for Nurses Needed Under the most favorable conditions service in a tuberculosis hos- pital or a contagious disease hospital is not regarded by nurses as attrac- tive. Efficiency on the part of nurses depends largely upon the comfort and convenience of their living quarters. It cannot be said that present accommodations for nurses at the health department hospital are ade- quate. 45 Sleeping quarters are provided for nurses and ward maids in the almshouse infirmary building. This building, of mill construction, was originally intended for caring for the insane, and at the time when the building was in use for this purpose it was nothing more than a jail. The nurses' dormitory is on the second floor, directly over the quarters of the almshouse infirmary patients. The unfaced brick walls and bare prison-like appearance of the rooms make them particularly unattrac- tive and dismal. The almshouse keeper complains that the almshouse infirmary patients are disturbed by the nurses above them, while the health physician states that nurses have no opportunity for off-duty recreation because of the fact that they do not wish to disturb the alms- house patients. There is no objection to the use of these quarters by nurses, pro- vided they are made more attractive; and indeed rooms could be made to serve every purpose with a few changes. The construction of a sound- proof floor, the increase of window space by the use of large panes and the cutting of additional window space would make rooms much more cheerful. Bare brick walls could be faced with plaster board without great expense and this would add unmeasurably to the appearance of the rooms. The dining rooms for nurses and maids are in the basement of the hospital. Owing to the fact that the basement is about one-half under ground, these rooms are dark and cheerless, although the nurses have attempted to make them attractive. Bare brick walls, dimly lit win- dows, and cement floors cannot be made cheerful. The enlargement of windows, the construction of a false floor of wood, a rug or two, and fac- ing of the brick walls would do much to make these rooms pleasant. Improved Stores Records Should Be Required Separate store rooms are provided in each of the two hospitals. Stores are issued by the matron upon requisition by the nurses in charge of diet, or the cook. There are no stores accounts showing accurately daily consumption per patient per day and the current condition of stores. It is recommended that such a stores accounting system be installed. For the purpose of determining the patient cost at the health department hospital, such records are necessary and a comparison of unit costs with similar records of other hospitals for tuberculosis and contagious diseases would furnish valuable information as to the effi- ciency of the plant. It would also be possible, having proper records of this kind, to purchase all provisions used on yearly contract. Butter, eggs, and flour are now sometimes purchased on short term contracts, but it is probable that all staples could be purchased on yearly contracts at a considerable saving. 46 Use of Private Laundry Dangerous Unclean, possibly dangerously contaminated linen from the health department hospital is carried into the city and washed in a private laundry with the linen of unsuspecting Springfield citizens. The health physician was unwilling to give the name of this laundry and he said that the practice would shortly be discontinued. The almshouse hos- pital maintains a laundry, and it is now building an improved laundry plant in another and more convenient location. When the new laun- dry is completed the health physician states that the old laundry will be available for use by the health department. There is every reason why the laundry facilities of the almshouse should be made use of imme- diately by the health department and the present procedure discontinued. It is admittedly a dangerous thing to allow linen used by patients with contagious diseases to be washed with linen from private homes where no disease exists and no excuse for this practice justifies its continuance. It is also a waste of money to have such work done in a private laundry. From December 1, 1912 to December 1, 1913, the health department hospital spent $1,844.75 for laundry service. The employ- ment of an extra force at the almshouse laundry to do this work would have saved probably one-half of this sum. Saving in the Purchase of Milk Probable From December, 1912 to November 30, 1913, the almshouse dairy farm produced from its six cows 41,45 1>^ quarts of milk, all of which was used by the almshouse. The almshouse master calculated the value of milk at the market rate of five cents per quart, although actual cost figures though not available were probably much less. The health department hospital purchased during this same period 17,400 quarts of milk at six cents per quart from an outside dealer and 3290 quarts from the same dealer at seven cents per quart. The total cost of milk purchased by the health department hospital was $1274.30. This same amount of milk could have been purchased from the almshouse dairy at cost, if provision of sufficient cows had been made. At five cents per quart, the market rate fixed by the almshouse master, $229.80 could have been saved in the purchase of milk alone. Three additional cows in the almshouse dairy, which is within a stone's throw of the health department hospital, would have furnished good, clean, wholesome milk at first hand. There would be much less danger of contamination in handling it and a supply would have been promptly available at any time. The amount saved in one year would be sufificient to pay for the additional cows needed. 47 Cultivation of Land Recommended Little attention has been given to the cultivation of the large plot of land owned by the isolation hospital for garden purposes. It is prob- able that if a sufficient amount of this land were put under cultivation by the isolation hospital, enough vegetables could be raised to supply easily the entire hospital. The health department hospital has been allowed for this purpose $8235 for the coming year. It is probable that the cultivation of health department lands would yield a saving of $1000 to $2000 per year, besides furnishing patients and employees with fresh vegetables at all times. ^^^tmmMmp'^' UNIVERSITY OF CALIFORNIA LIBRARY BERKELEY This I Return to desk from which borrowed. .,, p, D^JE on the last date ^ta]tip^^l>elow. XV-^JL^^'-'^'-^ LD 21-100m-7,'52(A2528sl6)476