THE ELEMENTS 
OF PUBLIC HEALTH ADMINISTRATION 
LUCKETT AND GRAY THE 
ELEMENTS OF PUBLIC 
HEALTH ADMINISTRATION 
BY 
GEORGE SPARE LUCKETT, A.B., M.D. 
H / 
DIRECTOR OF PUBLIC HEALTH, STATE OF NEW MEXICO; CHARTER FELLOW AMERICAN 
PUBLIC HEALTH ASSOCIATION 
/ 
AND 
HAROLD FARNSWORTH GRAY! B.S., M.S., Gr.P.H. 
CHIEF, DIVISION OF SANITARY ENGINEERING AND SANITATION, NEW MEXICO BUREAU OF 
PUBLIC HBALTH; MEMBER AMERICAN SOCIETY OF CIVIL ENGINEERS; FELLOW 
AMERICAN ASSOCIATION FOR THE ADVANCEMENT OF SCIENCE; MEMBER 
ROYAL INSTITUTE OF PUBLIC HEALTH; FORMERLY HEALTH OFFICER 
CITY OF PALO ALTO, CALIFORNIA, STATE DISTRICT HEALTH 
OFFICER, CALIFORNIA, ETC., ETC. 
PHILADELPHIA 
P. BLAKISTON’S SON & CO. 
1012 WALNUT STREET Copyright, 1923, by P. Blakiston’s Son & Co. 
PRINTED IN U. S. A. 
BY THE MAPLE PRESS YORK PA PREFACE 
In the fall of 1919, the authors were called upon to help 
construct an entirely new state health department, where 
no organized central health agency had previously 
existed. Among the many problems encountered was that 
of instructing the local, part-time health officers in their 
duties. Most of these physicians had been out of touch with 
modern health agencies for years; had been busy with their 
private practice, and were naturally unfamiliar with sani- 
tary procedure as conducted in other communities. To 
furnish a background of general principled, there was needed 
an elementary textbook on public health administrative 
methods, a simple, condensed summary that could be used 
as a ready reference by the practicing physician who was 
acting as health officer and who had no time to read the 
larger works. At the moment, no book which exactly 
fitted this requirement was available, so it seemed desirable 
to prepare a set of lessons and to issue them at regular 
intervals to the local health officers. The object was to 
tell them the “how” and the “why” of their official duties 
and to tell it in such a way that they could immediately 
apply it. Such was the beginning of this little book. It 
is in no wise intended to supplant the more comprehensive 
texts, but only to furnish a handy manual of practical 
suggestions. 
There is little that is new or unusual in the contents. 
The material is partly a condensation and combination of 
other textbooks and partly a presentation of the practical 
experience of the authors, an experience that has been gained 
in a variety of fields, from the Atlantic to the Pacific coasts, 
V VI 
PREFACE 
in national, state, county and city organizations. The 
suggestions offered here have all been put into actual prac- 
tice at one time or another. They may not all work every- 
where, but they possess at least the advantage of having 
succeeded somewhere and of forming a basis for procedure 
anywhere. Especially is this true of the forms and outlines 
gi ven in the appendix. While many men fail as health officers 
because of insufficient technical equipment for their work, 
more of them fail because they neglect the human factor. 
The aim here has been to show not only the way to accom- 
plish results, but also how to make the public understand 
and approve of the work when it is done. 
It will be noticed that nothing is offered on the subject 
of industrial medicine and hygiene. This is a specialty in 
itself and one that seldom concerns the average county or 
small town health officer. Therefore, it did not seem per- 
tinent to introduce subjects of little or no value in the 
day’s work. 
Acknowledgment must be made of the assistance of 
Surgeon C. E. Waller, U. S. P. H. S., who was associated 
in the preparation of the original lessons, reviewing and 
revising all of them at that time, and who wrote the chapter 
on Vital Statistics. Without his encouragement and help, 
it is doubtful whether the task would have been undertaken. 
It is only in deference to his expressed wish that his name 
does not appear as one of the joint authors. 
The attempt to make the book applicable to a wide 
range of conditions and at the same time reasonably brief 
has been found rather difficult. The effort to reconcile two 
such opposite aims will account in part for any deficiencies 
that may be found. However, it is hoped that the book 
will prove of practical value to new health officers of small 
communities; that it will be useful as a reference on admin- 
istration in some schools of public health, and that experi- PREFACE 
VII 
enced health officers will find in it a new viewpoint on 
some matters of policy and practice. To the end that it 
may become most useful to those for whom it is intended, 
criticism and suggestion are invited. In this connection 
we must express our appreciation of the helpful criticism 
and advice of our publishers and of Miss Helen B. Fenton, 
R. N., throughout the preparation of the manuscript in its 
final form. 
Santa Fe, New Mexico TABLE OF CONTENTS 
Page 
Preface v 
PART I 
Public Health Administrative Measures 
Chapter 
1. The Relation of the Health Officer to the Physician and the Public. 1 
2. Organization and Functions of Local Health Departments .... 8 
3. Finance and Management 20 
4. Office and Control System for Small Health Departments. ... 30 
5. Registration of Births and Deaths 41 
6. Vital Statistics 47 
7. Heredity and Health 60 
8. The Problem of Maternal Mortality 67 
9. Measures for the Prevention of Infant and Maternal Mortality .- . 71 
10. Infant Hygiene 75 
11. Child Hygiene 89 
12. Water Supplies 99 
13. Sewage Disposal 107 
14. Wastes Disposal, Sanitation and Housing 117 
15. Milk * ,129 
16. Foods and Food Poisoning 137 
17. Education and Publicity. 142 
18. Public Health Law 147 
19. Organization and Functions of State and Federal Health Depart- 
ments 153 
20. Public Health and Social Welfare 163 
21. The Future of Public Health 169 
PART II 
The Preventable Diseases 
Preliminary Considerations 181 
1. Anthrax 193 
2. Beri-beri 196 
3. Chickenpox 198 
4. Cholera 199 
5. Acute Contagious Conjunctivitis 203 
6. Dengue 205 
7. Diphtheria. . . ' 207 
IX X 
Chapter Page 
8. Dysentery 217 
9. Favus 220 
10. Filariasis 222 
11. German Measles 223 
12. Hookworm Disease 225 
13. Impetigo 228 
14. Influenza 230 
15. Leprosy 234 
16. Malaria 239 
17. Malta Fever 246 
18. Measles 249 
19. Meningitis, Epidemic Cerebrospinal (Meningococcic) 253 
20. Mumps 257 
21. Pediculosis 259 
22. Pellagra 260 
23. Plague 263 
24. Pneumonia 269 
25. Poliomyelitis 272 
26. Rabies 277 
27. Rocky Mountain Spotted Fever 282 
28. Scabies . . . 283 
29. Scarlet Fever 285 
30. Septic Sore Throat 290 
31. Smallpox 294 
32. Tapeworm Infestations . 302 
33. Tetanus 304 
34. Trachoma 306 
35. Trichinosis 309 
36. Tuberculosis 311 
37. Typhoid and Paratyphoid Fevers 319 
38. Typhus Fever 332 
39. The Venereal Diseases 335 
40. The Control of the Venereal Diseases 346 
41. Whooping Cough 357 
42. Yellow Fever 359 
PART III 
Appendix 
1. A Plan of County Health Work 365 
2. A Form of Statistical Report 374 
3. Instructions to Public Health Nurses 378 
4. A Plan of Emergency Organization for Relief in Epidemics.... 395 
5. A Course of Instruction for Midwives 400 
TABLE OF CONTENTS TABLE OF CONTENTS 
XI 
Chapter Page 
6. A Dairy Score Card and Instructions for its Use . . % 408 
7. A School Chart of Common Communicable Diseases 423 
8. Technique of (o) The Schick Test 425 
(6) Disinfection 426 
(c) Delousing Methods 429 
9. Forms 433 
10. Bibliography 446 
Index 451 PART I 
ADMINISTRATIVE METHODS OTHER THAN 
FOR COMMUNICABLE DISEASES CHAPTER I 
RELATION OF THE HEALTH OFFICER TO 
THE PHYSICIAN AND TO THE PUBLIC 
Many a promising health officer has had his life’s ambi- 
tion thwarted and his career ruined through failure to 
appreciate the fact that the human relation is the funda- 
mental thing in successful public work. The health 
official and many of his staff are in daily contact with the 
public, both individually and in mass groups. His whole 
work is constantly and inevitably PUBLIC, as contrasted 
with the relationship of the private physician to his patient. 
The impression he and his helpers make upon the public 
will determine quite definitely whether his work will 
continue to win popular support. And without sup- 
port from a majority of the public no governmental enter- 
prise can long continue. For the most part, people fail to 
discriminate between the person who does a piece of public 
work and the principle underlying the work itself. If the 
person is distasteful, his efforts are discredited, no matter 
how good they may be. 
Public health practice was originally an outgrowth of 
medical knowledge. The facts that were learned regarding 
the sources and modes of infection were applied by govern- 
ment in an effort to protect its citizenry from sickness and 
death. It was most natural that only medical men should 
be entrusted with this duty, since they were then the only 
ones who had the requisite training. Even today, a large 
portion of public health work is based upon medicine and 
the majority of health officers are physicians. What is 
1 2 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
more natural, then, than that the physicians of the com- 
munity, with no training in the other aspects of public 
health practice, should regard the work of the health 
officer as purely medical? Such being the case, his program 
and bearing are judged from the restricted viewpoint of a 
private practice and his public acts thereby fall under 
censure in the minds of the profession, especially at the 
outset of his work. Particularly is this true of the pub- 
licity, that is so essential to a health department’s cam- 
paigns, and of the various clinic activities that every well 
organized department must maintain. 
Fortunately, there are usually a few physicians in the 
community who take a broader view of public health 
work and through them the health officer can create a 
more friendly atmosphere. Education of the local pro- 
fession in the fundamentals of public health practice 
is an important function of the health officer. If he is a 
physician, he should make it a point to join the medical 
society at the earliest possible moment and take every 
opportunity to present his subject in an interesting and 
attractive light, avoiding always the didactic as much 
as possible. The matter offered should deal with those 
phases of public health which are neglected or ignored in 
the average medical school and of which the average 
medical graduate has little or no conception, such as 
the value of morbidity reports and vital statistics, 
maternal, infant and school hygiene, epidemiology, general 
sanitation, etc. 
Sooner or later, every health officer will be confronted 
with the problem of dealing properly with physicians who 
persist in their failure to make the reports required by law. 
After repeated warnings, there can be but one course to 
follow, viz., prosecution. To the rightminded person this 
is extremely distasteful, but, like a dose of castor oil, RELATION OF HEALTH OFFICER TO PHYSICIAN 
3 
something that is occasionally imperative, if the work of 
the department is to progress and to command the respect 
of the community. It should always be made clear that 
legal procedure is a last resort into which the official is 
forced against his wishes, but which he is compelled to 
apply in the protection of the public. Very little of this 
sort of thing is necessary, if the health officer has made the 
right kind of contact with the local profession. 
On the other hand, the medical health officer will have to 
guard against becoming so deeply involved with his profes- 
sional brethren that he loses sight of his public relation. 
An even balance is difficult but essential. However, this 
consideration should not deter the health officer from giving 
every aid in his power to physicians who may call upon 
him for help. He can frequently make a friend for his 
department by going out of his way to render service. 
At all times his relationship with the profession should be 
strictly ethical according to the accepted standards, which 
is nothing more than true courtesy. 
Bearing this in mind, the health officer should have little 
difficulty in choosing the proper course when handling 
cases of communicable disease. The attending physician 
is in charge of the PATIENT and his rights must be 
respected; while the health officer is in charge of the imme- 
diate and remote ENVIRONMENT, including contacts, 
sources of infection and potential cases. The two functions 
are distinct and this difference should constantly be empha- 
sized to the profession. The physician holds a private 
relationship in respect of his patient; the health officer 
holds a public relationship in respect of the community 
that employs him. The chief duty of the one is to protect 
the interests of the individual, while the other is charged 
with the protection of the public as a whole. The question 
of diagnosis is often the rock upon which cordial relations 4 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
between physician and official are wrecked. What is the 
duty of the health officer? Measured by the yardstick of 
his public function, there is but one solution of the problem, 
viz., to act upon his own best judgment as to the nature of 
the case, regardless of any other diagnosis made. The 
public interest is paramount. However, guided by the 
dictates of courtesy, he can avoid giving offense to the 
physician by saying frankly that the two disagree; that 
he may be wrong, but that he has no other course to 
pursue than to rely upon his own verdict, and that where 
there is a reasonable doubt, the health officer must act 
on the presumption that the disease is communicable. 
He should avoid as far as possible any implication that 
might destroy the confidence of patient and family in the 
medical attendant. 
An important function of the health officer in his relation 
to the public is that of advisor and teacher in the whole 
field of hygiene. His position is comparable to that of the 
safety engineer, engaged by a large manufacturing plant, 
who not only plans and supervises safety measures, but 
conducts educational programs among the employees 
and advises the management as to the causes of, and 
remedies for, possible accidents that may occur in the 
future. In order to teach, the health officer must inspire 
confidence, and to do this requires that he give evidence of 
sound training and a well balanced mind. The man who is 
constantly running after fads or propounding mere 
theories as facts is soon found out and discredited. Not 
only must his teaching be authoritative, but it should be 
couched in such terms that the less intelligent groups of 
the community may grasp the ideas presented. As expert 
advisor to the governing authorities the health officer must 
be sufficiently well trained to discover potential sources of 
disease and suggest practicable means for their eradication. RELATION OF HEALTH OFFICER TO PHYSICIAN 
5 
His knowledge of the experiences of other organizations 
should be such that he can advise upon the feasibility of 
plans for the various kinds of welfare work that are suited 
to his own community. 
Cordial relations with the governing authorities must be 
maintained, otherwise many hindrances to the smooth 
working of the department will arise. This does not mean 
that the health officer should be a politician in the ordinary 
sense of 'the term. On the contrary, the reproach of 
“playing politics,” of using the office to further any one’s 
political ambitions, will undermine the most effective 
organizations, for public health can know no creed, politics 
or sect of any kind whatsoever. It should be a plank in 
the platform of every party or faction. 
Next to the minister and family physician, the health 
officer probably knows more of the intimate details of 
family life in the community than any one else. His work 
is often of a most personal nature, and his ethical standards 
should, therefore, be of the highest order. Granting that 
such is the case, he will inevitably gain the confidence and 
respect of many individuals who will help to create that 
body of popular approval upon which depends the perpet- 
uation of the work. 
Not only does the health officer constantly meet the 
individuals of the community in close contact, but he must 
learn to deal with the public in groups, to use that elusive 
something called “mass psychology,” to develop his gift of 
leadership, to the end that popular movements may be 
directed toward the goals for which he is striving. This 
involves, among other things, the proper kind of advertising, 
of keeping the public regularly informed of the depart- 
ment’s activities, and necessitates a friendly relation with 
the press. For the average physician, schooled in reticence 
and modesty, such publicity is anathema. The health 6 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
officer must learn that he is no longer a private person, but 
a public servant, and that the success of his undertakings 
depends entirely upon informed public opinion. Wisely 
used, this publicity becomes at once both a means of 
educating the public and of gaining the support that is 
needed. The ancient truism that a fountain can rise no 
higher than its source is amply illustrated in public health 
work. Until public ignorance, indifference and inertia are 
overcome, until there is a determination on the part of the 
public to have better health conditions, the health officer 
will fail, regardless of his personal industry, and law enforce- 
ment will become a farce. 
After all, then, the success of a health department depends 
not so much upon its financial resources and equipment as 
upon the character of the man at its head. His personality, 
intellectual makeup and human understanding are the 
determining factors in organizing and popularizing his 
program. It seems worth while, therefore, to mention 
some of those characteristics that are found in the effective 
health officer. 
1. PATIENCE must head the list, for the man of short 
temper is also usually short on judgment and inclined to 
resort to force before he has exhausted the possibilities of 
education. 
2. TACT in handling the daily problems that arise wins 
friends where many enemies may easily be made. 
3. PERCEPTION of the viewpoint and intelligence of 
those with whom he comes into contact is the foundation of 
tact. 
4. SINCERITY coupled with INDUSTRY create in the 
public mind the conviction that the health officer has the 
community good at heart. 
5. FIRMNESS AND DECISION in carrying through a 
determined policy are the complements of sincerity. RELATION OF HEALTH OFFICER TO PHYSICIAN 
7 
6. Thorough KNOWLEDGE of his specialty fosters 
confidence in, and respect for, the official and his acts, but 
this special knowledge should be founded on broad general 
education and culture. 
7. Based upon knowledge is GOOD JUDGMENT in 
dealing with questions of policy and administration. 
8. There must be absolute FAIRNESS to all, with 
nothing of personal animus in any action. 
9. COURTESY always. CHAPTER II 
ORGANIZATION AND FUNCTIONS OF A LOCAL 
HEALTH DEPARTMENT 
The local health department is the public’s real point of 
contact with public health work. It is therefore the most 
important single agent in the public health campaign. 
Without effective local health departments, the health 
campaign is as impotent as that of an army consisting of a 
general staff but no soldiers. Putting a health program 
into effect requires the presence of a man or an organization 
on the ground actively and promptly attending to the 
thousand and one details constantly requiring attention. 
A central state organization cannot do this detail work. 
In the first place, the central state organization is too far 
from the persons who present the problems, and cannot 
have that direct touch with conditions necessary to get 
immediate results in the individual cases. In the second 
place, if the central organization attempts to handle the 
details of local affairs, it cannot perform its own proper 
functions of coordinating, standardizing and supervising. 
Another important consideration is that of local pride. A 
community will usually have pride in a good thing of local 
origin, and remain indifferent to something just as good but 
not its own. A wise health officer develops and stimulates 
this local pride by making his people proud of their health 
department. 
The functions of local health departments group them- 
selves as follows: 
8 A LOCAL HEALTH DEPARTMENT 
9 
I. Registration and Interpretation of Vital Statistics. 
(а) Births. 
(б) Deaths. 
(c) Communicable diseases. 
(d) Reports to State Health Authority. 
II. Control of Communicable Diseases. 
(а) Verification of diagnoses. 
1. Clinical. 
2. Laboratory. 
(б) Investigation of sources of infection. 
(c) Searches for carriers and “missed” cases. 
(d) Isolation and quarantine procedure. 
1. Establishment. 
2. Supervision. 
3. Release. 
4. Terminal disinfection. 
(e) Exclusions from school and readmissions, on account of com- 
municable disease. 
III. Child Hygiene. 
(a) Prenatal work. 
(b) Infant hygiene. 
(c) Care of the preschool child. 
(d) School hygiene and medical inspection of school children. 
IV. Sanitation. 
(a) Water supply. 
(b) Sewerage. 
(c) Wastes disposal. 
(d) Rodent destruction. 
(e) Prevention of fly and mosquito breeding. 
(/) Industrial sanitation. 
(g) Nuisances. 
V. Housing. 
VI. Milk and Food Sanitation. 
(а) Milk. 
1. Inspection and scoring. 
2. Laboratory. 
3. Pasteurization. 
4. Standards and grading. 
5. Permits. 
(б) Meat inspection. 
(c) Sanitation of food-handling establishments. 
VII. Education. 
(a) Printed matter. 
(b) Newspapers. 10 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
(c) Lectures and talks. 
(d) Visual (motion pictures, etc.). 
VIII. Clinics. 
(а) Well-baby. 
(б) School. 
1. Medical. 
2. Dental. 
(c) Venereal. 
(d) Tuberculosis. 
(e) Special (e.g. hookworm and life extension). 
Many of these functions are considered in some detail in 
other chapters, but at this point a few statements of practi- 
cal value, with reference to the above outline, are in order. 
I. The health officer must be a “go getter” in respect of 
certificates of birth and death, and reports of communicable 
disease. He cannot know either the current state of 
health of his community, nor whether his work is effective, 
unless he has complete and accurate records. He should 
learn to study and classify these records according to 
proper statistical methods and to interpret them accu- 
rately in terms interesting to, and understandable by, his 
community. 
II. (a) The final decision as to questions of diagnosis in 
communicable disease rests with the health officer, or, on 
appeal, with the state health authority. But this decision 
should be made both justly and tactfully, so as to secure 
the cooperation of the local medical profession. The health 
officer ought to verify diagnoses. Where he disagrees, he 
should use the greatest tact and discretion, and endeavor 
to have the attending physician change to -the correct 
diagnosis by skillful suggestion. Let him “save his face” 
before his patients. 
(6) and (c) These are very important parts of the health 
officer’s duty. They are comprised under the term “epi- 
demiology.” The first question which should come to A LOCAL HEALTH DEPARTMENT 
11 
mind is, “What was the source of infection in this case?” 
The source must, if possible, be found, so as to control it 
and. prevent further infections. The second question should 
be, “Who are the contacts with this case, or possible 
carriers, who may spread the infection?” They must be 
found promptly and controlled. 
Do not stop with the isolation of the case. That is only 
the beginning. Each case should be simply the starting 
point for an investigation which should not cease until the 
source of infection and all ascertainable avenues of spread 
have been discovered and controlled. 
(d) The mechanics of isolation and quarantine, such as 
placarding, supervision and release, may be performed by 
the health officer’s assistants (inspectors and nurses), thus 
relieving him of routine. But he must exercise sufficient 
supervision to see that this work is properly and effectively 
done. It is particularly important to oversee concurrent 
disinfection in the homes of the ignorant and slovenly. 
Although routine, the manner in which isolation and 
quarantine, release and terminal disinfection are per- 
formed can make or break a health department. The 
work should be so systematized and standardized that it 
takes a minimum of time and expense, and at the same time 
must be’done tactfully. People are apt to be a bit upset in 
"sickness. Courtesy and consideration, but with 
firmness in requiring compliance with the regulations,! are 
necessary. 
(e) Remember that the health officer usually has no 
authority to exclude a child from school. It is the duty of 
the school authorities to exclude. Secure team-work and 
cooperation with them. Make it easy for them to do their 
part. If necessary, make them do it by legal measures as 
a last resort, but do not attempt to do their job or exercise 
their authority. Of course, the health officer can always 12 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
quarantine children who have been exposed to disease, if 
they are likely to spread infection. 
III. The field of infant and child hygiene offers nearly 
one-third of our opportunity to reduce the community 
death rate. It is also the field of work which as a rule 
receives the greatest public support. Enlist that support, 
and do the work. When results are secured, remember 
to say, “We did it,” not “I did it.” Give plenty of credit 
where due. Make friends with the children and make them 
friends of the health department. Today’s children are 
tomorrow’s voters. 
IV. (a), (b) and (c) Water supply, sewerage and wastes 
disposal are engineering problems. They are best handled 
by the municipal Department of Public Works, or its 
equivalent. The health officer should cooperate and advise, 
but he should not attempt to handle these matters himself, 
except in special cases. He should actively campaign for 
100 per cent, sewer connections, or for sanitary privies where 
there are no sewers. He should make inspections to see that 
the water supply is not being contaminated. He should see 
that manure and garbage are not permitted to accumulate 
so as to breed flies. But he should not boss the sewer 
department, nor run the waterworks, nor operate the 
garbage collection system. 
(d) The best approach in industrial sanitation is to show 
the employer the gain in efficiency of his labor force which 
will occur if they work under sanitary conditions. Do not 
try compulsion until every appeal to self-interest has 
been exhausted. 
(e) “Nuisances” are nuisances to the health officer as 
well as to the complaining citizen. Often the complaint has 
little to do with public health. But do not argue the case 
with the complainant. Thank him! It may be that he 
complains to the health officer, when it is the proper A LOCAL HEALTH DEPARTMENT 
13 
business of the street department or the police. If so, 
refer it to the proper officials. Ask them to attend to it 
properly. Then the citizen will say, "We have a real 
health department. I called up the health officer and he 
sent a man right out and removed the dead dog in front 
of my house.” Next time he may have something im- 
portant to report and will do so with confidence that it 
will be attended to. 
V. Spend plenty of time on milk inspection. If possible, 
the health officer should have a small laboratory and make 
bacteriological examinations of the milk. Score dairies 
by the standard score card and publish the scores and the 
results of the bacteria counts. The public is interested, 
and it stimulates the dairymen to compete for a high 
standing. Improvement of the milk supply helps to reduce 
infant mortality, especially in summer. It is worth con- 
siderable effort. But do not spend too much time on other 
food inspection. Do enough to satisfy the public that the 
matter is being given adequate attention. Medical inspec- 
tion of food-handlers is more important in reducing 
communicable disease than is sanitary inspection. Do 
both, in proper proportion. 
VI. Keep the public constantly informed as to the work 
of the health department. Report results. Tell the news- 
papers what is being done. It is news, and they are glad 
to print it. A good editor or reporter can help to give an 
understanding of just what constitutes “news,” and how it 
should be presented to interest the public. Keep the work 
before the public, with favorable comment if possible. 
Even criticism is better than indifference. To the average 
physician such publicity may be a bit distasteful, but as 
health officer he is a public personage, performing a work 
in which the public is interested and concerning which 
it has a right to definite and complete information. The 14 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
right kind of publicity helps the work. But it should 
actually advertise the department, not the man. Use the 
“news” as a hook on which to hang some useful piece of 
health education. The public will seldom read a health 
article, but by tying the same information, briefly and 
concisely, to a news item it will carry the message. 
VII. In a few diseases adequate treatment or cure of a 
case is an effective public health measure, in that it elimi- 
nates a source of infection. For this reason, venereal and 
tuberculosis clinics have a definite place in the health 
program. On the other hand, well-baby and school clinics 
have a valuable place in health work because they correct 
defects which may lead to disease or physical deficiency. 
Free “life extension” examinations for the adult popu- 
lation is also excellent preventive work. Make the clinics 
preventive as well as corrective. In the smaller communi- 
ties they must be carried on largely by voluntary coopera- 
tion of physicians and dentists. It is unwise to organize 
a clinic until there is a satisfactory means of following up 
each case to ensure cooperation of the patient, regular 
attendance and the correction of harmful social conditions 
that may prolong the illness or produce a recurrence. 
How should the local health department be organized 
to effect the results desired? 
In the first place, there must be a single executive head. 
This man is usually designated as the health officer. Often 
this is as far as the organization goes, and the health officer 
acts as executive, medical inspector, sanitary inspector, 
laboratory technician and clerk, all in one. When this is 
the case (as it usually is in small counties and villages) 
the problem is one of organizing his own time, rather than 
of directing the work of others. Fortunate is the state that 
has abolished the obsolete local “Board of Health,” and 
placed the responsibility and duty of enforcing health laws 15 
A LOCAL HEALTH DEPARTMENT 
squarely upon the health officer. Several heads may be 
better than one for counsel, but one head is much the best 
for action. 
The usual personnel of a small full-time health depart- 
ment is the health officer, a public health nurse, a sanitary 
inspector, a laboratory technician, and a clerk. The last 
two positions are sometimes combined. This is about the 
minimum practicable organization. Expansion of this 
minimum follows along the line of adding specialized nurses 
and inspectors, as infant hygiene nurses and school nurses, 
or dairy inspectors and food inspectors. In addition, 
clinic physicians and various medical inspectors may be 
added to the staff. Special clerks may be detailed to 
handling the statistical work only. At least the health 
officer and the minimum staff must devote all their time to 
their duties. Outside interests, especially if profitable, 
work against adequate attention to duty and inevitably 
result in a neglect of the public business. Some of the 
staff, however (clinic physicians and medical inspectors) 
may well be on a part-time basis. 
Each one of the positions indicated requires definite 
qualifications for successful work. The health officer must 
be an efficient executive. No amount of technical knowl- 
edge will compensate for lack of administrative ability. 
He must be able to plan his work, and then direct his sub- 
ordinates toward the definite aim of that plan. He must 
also have a pleasing personality. He should also be 
broadly educated, rather than merely “stuffed” with 
technical information. Further, the health officer must have 
a public health training and viewpoint. A medical training 
is not sufficient. It requires a mental wrench for the average 
physician to readjust his ideas when entering public health 
work without special preliminary training. He is apt to 
have the individual or personal viewpoint, as developed from 16 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
contact with his patients, rather than the public viewpoint. 
He is apt to adopt the “ex cathedra” attitude, which is all 
very good with his sick patients, but reacts the wrong way 
on the well public. Without special public health training 
the average physician is without knowledge of statistical 
procedures; his epidemiology is apt to be hazy; he knows 
little about dairy inspection, housing, industrial sanitation, or 
the engineering health problems. Even more important, he 
knows nothing, or next to nothing, about public health law, 
or the subjects of municipal finance, budgets and accounting. 
Although these limitations look formidable, yet in spite of 
them a physician with the proper personality is to be pre- 
ferred as a rule for the position of local health officer. 
Public opinion usually requires it, and a physician can do 
properly and legally a number of things that it is best that a 
non-medical health officer should not attempt, even if by 
special knowledge he were qualified to do so. It should be 
admitted, in fairness, that many specially trained non- 
medical men have made brilliant successes as local health 
officers. We doubt if any state, on the whole, has better 
local health administration than either Massachusetts or 
New Jersey, and in both these states there are non-medical 
health officers doing valuable work. Usually they are 
graduate sanitary engineers with a post-graduate public 
health training. To boil the matter down to essentials, 
it is not the particular combination of letters after a man’s 
name, but his knowledge, ability and personality, which 
bring success in this, as in any other field of endeavor. 
Where there is much diagnostic work to be done, or 
clinics are a part of the department’s work (and also where 
the health officer is not a physician), one or more medical 
inspectors are a part of the staff. These men must be 
skilled diagnosticians, tactful, and with pleasing personali- 
ties. Not every physician makes a good medical inspector A LOCAL HEALTH DEPARTMENT 
17 
for the reason that he often fails to recognize the early 
stages of communicable disease, or the mild, atypical 
cases. This is especially true in scarlet fever and smallpox. 
The public health nurse should be a graduate nurse, 
from a standard training school, a registered nurse if 
possible, and with at least some special training in public 
health nursing. They should have an abundance of tact 
and discretion, pleasing personalities, and some teaching- 
ability. No members of the staff are in such intimate 
personal contact with the people as the public health nurses, 
and great pains should be taken in their selection. 
In selecting inspectors, not so much stress need be laid on 
technical training. Active, intelligent, observant young 
men of good address can be made into satisfactory inspec- 
tors with study and with training that the health officer 
can give them. Meat inspectors, however, should be 
graduate veterinarians, and a graduate veterinarian usually 
makes the best dairy inspector. 
The laboratory technician should certainly be well- 
trained in bacteriology, but need not, in a small department, 
be an expert, if the health officer can personally supervise 
the work. Women make excellent bacteriologists, being 
careful and willing to take the infinite pains with details 
that this work requires. In small health departments the 
bacteriologist can also act as clerk. 
In planning the work of his department, the health 
officer should endeavor to adjust his work in such a manner 
as to obtain the greatest results from his efforts. In order 
to do so, he should have some knowledge of the relative 
values of the different phases of public health work. 
Several attempts have been made to evaluate public health 
procedures. One of the most logical is that of Franz 
Schneider, who, after a series of interesting calculations, 
has arrived at the following results: 18 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Per Cent 
1. Control of communicable disease: 
(a) Tuberculosis 12.1 
(b) Venereal diseases 6.6 
(c) All others 25.3 
2. Infant hygiene 20.3 
3. School inspection 7.0 
4. Privy and well sanitation 3.5 
5. Fly and mosquito control 2.4 
6. Milk control 2.7 
7. Food sanitation 0.1 
8. Vital statistics 5.0 
9. Laboratory 5.0 
10. Education 5.0 
11. Clinics 5.0 
Total 100.0% 
Table I 
This table was based on average conditions and the 
relative values will vary in different parts of the country. 
For example, in unsewered towns and malarial districts, 
fly and mosquito control will have a higher relative value; 
in towns of low moral standards, venereal disease control 
measures may be rated higher. A different emphasis 
might be given to various items in rural districts from that 
given in large cities. 
Although much of the preceding discussion has dealt 
chiefly with the problems of municipal health departments, 
it is applicable also to county health work. The emphasis 
must be changed, but otherwise the statements are valid 
for rural districts. In the country and the small towns 
more attention must be given to sanitation. While in the 
city sanitation may best be handled by the department 
of public works, in the country the health department 
must do it. Privies and wells, flies and mosquitoes, are 
larger problems in the rural districts. Food and milk sani- 
tation is somewhat less important in the country than 
in the town. Housing is less urgent, as there is less over- A LOCAL HEALTH DEPARTMENT 
19 
crowding, and more wholesome outdoor exercise. Clinics 
are of little value in rural districts, unless they are traveling 
clinics, but visiting nurses and visiting medical and dental 
inspectors are highly useful. 
In counties where the towns are comparatively small 
(say less than 25,000 population) there is a tendency to 
consolidate into one health department for the county and 
all the incorporated towns. This scheme has many 
advantages and but few defects. It enables the entire 
county to have a full-time health organization at a reason- 
able expense, that would be almost prohibitive if a single 
community were to attempt it alone. There is also the 
advantage of uniform control over the entire area. As a 
rule, the county seat is the center of business and social 
life for the county. A unified health department gives 
the health officer supervision over the many sources of 
infection and the movements of contacts. CHAPTER III 
FINANCE AND MANAGEMENT 
Every health officer has to face two problems of the 
utmost importance. One is the obtaining of funds to 
carry on his work. The other is the management of these 
funds to secure the best results. Because these subjects 
are so dependent upon popular opinion, they will be dis- 
cussed in connection with methods for building a public 
opinion favorable to an adequate support of health work. 
Health officers must realize keenly at all times that public 
health work is a function of government, a part thereof, 
and that funds for maintenance are derived from taxation. 
The more the health. officer knows about governmental 
forms and practices, and especially governmental finance, 
the better able, he will be to cope with the governing 
authorities to whom he looks for appropriations. It is 
highly desirable that every health officer thoroughly 
study some good texts on governmental forms and finance, 
such as Bryce’s “American Commonwealth,” Munro’s 
books on municipal government, and Plehn’s “Introduction 
to Public Finance.” 
As a general rule, the money for the operation of a health 
department is obtained through the operation of a “bud- 
get.” This is simply a financial plan for the operation of 
a state, county or municipality for a fiscal year. The 
budget, or financial plan, is based upon the estimated needs 
for the operation of the entire government (state, county 
or city) for the next fiscal year, after these needs are bal- 
anced against the estimated revenues. Many budgets 
20 FINANCE AND MANAGEMENT 
21 
are crudely made. Politics, favoritism, prejudice and pre- 
cedent frequently play a larger part in their construction 
than analysis of necessities, or sound public policy. Cer- 
tain departments which are well established, as the courts 
and the police, are apt to get practically what they demand, 
while the welfare departments, often public works, and 
at times even fire departments, get less than should be 
expended to obtain satisfactory results. 
It is a standing complaint that health departments are 
inadequately supported financially. Very often this is 
due in large part to a failure of the health officer to play 
the game according to the rules. If he is a purely political 
appointee and stands in with the “gang,” he seldom knows 
anything about public health practice, and cares less. 
Places are made for political workers, and enough “pap” 
handed out to go with these jobs; but no attempt is made to 
work out a financial plan on the basis of the health needs of 
the community. 
On the other hand, if a physician inexperienced in public 
health work is appointed, he may adopt the “ ex cathedra ” 
manner, and try to tell the governing board what to do. 
This manner works very well with his patients, but doesn’t 
go at all with the town council. The town board resents 
being told. Even when the health officer asks, he must have 
some strong support back of the request, and then stay 
everlastingly on the job until he gets the amounts needed. 
The full-time, trained and experienced health officer is in 
a better position to obtain funds than either of the former 
types, if he analyses his needs and presents a comprehensive 
budget analysed, explained and fully supported by data 
and a public demand. 
The request for funds should be made up in a tabular 
form, in considerable detail, but grouped under a few main 
headings, such as salaries, transportation expense, equip- 22 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
ment, operating expenses, contingencies and miscellaneous. 
In large health departments these groups may be prepared 
for each bureau or division separately, but in small depart- 
ments segregation functionally by divisions or bureaus 
is unnecessary. Each item should be numbered or other- 
wise designated and explained concisely in a supplemental 
sheet, the two together forming in effect a plan of work and 
a detailed statement of its cost. This plan should then 
be given to each member of the governing board and gone 
over in person with him, explaining every item on which 
there is the slightest question. 
In planning the estimate, it is well to keep in mind a 
table of relative values in public health work, such as 
Schneider’s or Chapin’s. As nearly as possible expenditures 
should conform proportionately to the ultimate value, 
from a health standpoint, of each activity or function. 
In small departments this is difficult, if not almost impos- 
sible, and in large departments statutes and ordinances 
may interfere by requiring the performance of certain 
phases of the work on a greater scale than proper balance 
would justify. But within such limits a balance of expendi- 
tures by function should be obtained, in accordance with 
the importance of each function as it relates to the saving 
of lives, the improvement of living conditions or the pro- 
motion of positive health. 
One health officer who has been quite successful in obtain- 
ing his budget requests made it a practice to begin work on 
the budget several months in advance of the time of presen- 
tation, at the same time launching a definite campaign to 
get it through. Supporters of the department were asked 
to see members of the town council at intervals, and in a 
general way ask for adequate financial support for the 
health department. This gave the impression of a strong 
public interest and support. When the preliminary esti- 23 
FINANCE AND MANAGEMENT 
mates were called for, he took his figures to each individual 
councilman and explained them thoroughly. When the 
budget committee met, he was on the job, regardless of 
whether his estimate was under consideration or not, and 
made himself generally useful in checking and computing 
and displayed an interest in the entire proceeding. This 
being “on the job” was kept up until the entire council 
had passed the budget and the matter was closed. At the 
council meeting on the budget he always had a large 
delegation of influential citizens present and they discreetly 
let it be understood that they were there to see that the 
health department got what it needed. He found that the 
councilmen were favorably influenced by these measures, 
and he managed to get increases each year in spite of 
occasional strenuous opposition. 
While the method may not be followed in detail in every 
community, the underlying idea of a concerted campaign and 
constantly being on the job can be carried out everywhere. 
There are two general types of budget, the “segregated” 
and the “lump sum.” In the former the various amounts 
allowed are specified in more or less detail; while in the latter 
a single lump sum is allotted to each department or function. 
The lump sum budget is practically worthless to the govern- 
ing board as a means of controlling expenditures, and a 
too greatly segregated budget may prove inflexible in 
emergencies or under suddenly changed conditions. 
Beware of too great segregation in the budget, but give 
considerable detail in the estimates, to show the reason 
for the requests under the major items of the final budget. 
In preparing the estimates it is almost essential that a 
comparison be made with the actual expenses in the 
previous year, or better the previous two or three years. 
In order to be able to make such a comparison it is necessary 
to have an accounting system which will show how the 24 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
money has been spent, both by the kind of expenditure, 
such as salaries, equipment, postage, printing, etc., and by 
function, as for preventable diseases, vital statistics, sani- 
tary inspection, child hygiene, etc. If the auditor or clerk 
does not keep such a record, the health officer should do so 
himself for his own protection and guidance. 
When operating under a budget, it is helpful also to 
divide the various allotments into twelfths, and each month 
check up to see whether expenses have run over or under 
the average, and whether the total expended to date is 
more or less than the proper proportion. If possible it is 
best to spend a little under the average allotment, so as to 
have some reserve for emergencies. At the end of the fiscal 
year any available surplus can be easily expended for sup- 
plies for the next year, if the budget is not too rigidly 
segregated and detailed. 
Adequate appropriations are the life-blood of a health 
department. Everything the health officer does should be 
performed with an idea, at least in the back of his mind, 
as to how such action will ultimately affect his budget. 
By that we do not mean that any “pussy footing” or 
“trimming” should be resorted to, but that positive efforts 
to affect favorably the opinion of the appropriating body 
should be always in mind. This opinion may be affected 
both directly and indirectly, and the campaign should be on 
at all times, merely being intensified and strongly focused 
when the annual budget is under consideration. 
The people who form public opinion may be roughly 
classed as 
1. Officials 
2. Leading Citizens 
3. Organizations 
4. Average Citizens 
5. Kickers. FINANCE AND MANAGEMENT 
25 
Each of these groups should be reached in a slightly 
different manner, but all can be brought to support the 
health department if skillfully handled. 
The governing board or council should be kept in close 
touch with the work of the department. Monthly and 
annual reports should be presented to it, but as reports 
are seldom read, it is best to take up individually with each 
member the “high lights” of every report. Keep them 
informed and consult them as to general policies. If 
possible, the health officer should get each member to do 
him an occasional favor, and in return he should give these 
officials credit for any success he may have. 
If the health officer is working under a city manager, 
many difficulties are avoided, as there is one man rather 
than many to deal with in respect of most administrative 
matters. But, aside from the city manager, there is a 
whole family of officials whose good will is valuable and 
whose cooperation is often very helpful. 
The police have access to information of use to the health 
officer, and they also can be helpful in reporting nuisances, 
quarantine breaking and other matters of interest. As a 
rule, this help can only be obtained if the health officer 
cultivates the chief and the individual officers, and gets these 
reports as friendly assistance. Any attempt to force this 
assistance through executive order or direction usually is a 
failure. 
The fire department also will be an ally, especially if 
much interested in fire prevention work. Rat-harbor and 
fire hazards are often closely linked, for example. 
The school authorities almost always cordially cooperate 
with the health authorities. But they must be handled 
carefully, and the health officer must not even seem to 
interfere within their jurisdiction. Schoolmen have their 
pecularities, and are generally a bit sensitive. If the health 26 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
officer can make them feel that each is cooperating with the 
other for mutual benefit, relations will be on a better basis 
than if there is no evidence of their being an important 
part in the cooperation. Playground and recreation 
officers, and the department of charities and corrections, 
are natural allies of the health officer, and this natural 
tendency should be strengthened by courteous and helpful 
cooperation by the health officer. 
Long before it is ever necessary to take a case into court 
the health officer should be personally well acquainted with 
the local judges. It is highly advisable to talk informally 
with them about health work, and give them a clear insight 
into what the health officer is doing and trying to do. The 
health officer should try to get them to instruct him in the 
proper legal procedure to take in the various cases that 
might come up, and also he should learn the local court 
customs and prejudices, if there be any. After several 
interviews on a general friendly basis, it is w'ell tactfully 
to try to get them committed to a general policy of en- 
forcement of health laws, without reference to any specific 
cases. The prosecuting attorney should also be made 
a friend. Then when it finally becomes necessary to go 
into court the health officer’s way is easier and that of the 
transgressor harder. 
When working in rural districts the agricultural agent or 
farm advisor, and his co-worker, the home demonstration 
agent, are valuable allies, who are almost always glad to 
cooperate with the health officer and have him cooperate 
with them. The rural people can probably be reached 
more easily through their Farm Bureau meetings in various 
parts of the county than in any other way. The agri- 
cultural agent is the man to put the health officer before 
these meetings on the best possible basis. FINANCE AND MANAGEMENT 
27 
All the members of the official group form a body of public 
opinion and assistance which can be quickly brought to the 
health officer’s aid, if he has made friends with them. 
Equally, if not more, important are the “ leading citi- 
zens,” who are often the “ power behind the throne.” It 
is necessary for success to find out promptly who these 
men and women are, and to cultivate their acquaintance 
in a friendly yet dignified way. Each one must be studied 
individually, to learn what his fundamental motives are, 
and what are his greatest interests. There are no “ rules 
of the game” with leading citizens; make as many as possible 
your friends and allies by whatever means seem honorably 
possible. The more of them who will go to the bat for the 
health department when it strikes difficult times, the safer 
the health program of a community will be. 
Leading citizens and officials are the most quickly mobi- 
lized group of public opinion. The next are the various 
organizations, such as the Chamber of Commerce, Rotary 
and Kiwanis Clubs, Women’s Clubs, Farm Bureaus, etc. 
These can help greatly, often unselfishly, but as a rule the 
greatest results are obtained from them if they can be given 
something definite and concrete to do, such as drives and 
clean-up campaigns. Occasional talks, brief and pertinent, 
before these organizations, backed up by a personal 
acquaintance among their memberships, help to build a 
second body of public opinion favorable to the health 
department, and which can be mobilized fairly quickly. 
In the long run the underlying and decisive public opinion 
is that of the average citizen. He is, however, rather 
difficult to reach quickly, and his reactions to health work 
are mixed, sometimes uncertain and usually slow. As a 
rule, however, he tends to support an official agency which is 
actively and effectively doing its job, provided he finds it 
out in a convincing manner. Steady newspaper publicity 28 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
helps with the average citizen. The health officer, his 
inspectors and especially his public health nurses can gradu- 
ally reach a considerable part of the population, and in time 
build up a prestige based on good work pleasantly and 
efficiently performed. 
There are always present a small number of chronic 
kickers, in any community. They are annoying, but 
seldom need be taken very seriously. It is well to listen 
to them courteously; to sympathize with them if possible; 
to soothe and appease them as tactfully as may be. With 
those who cannot be handled, the best policy is to be patient 
and forebearing. Chronic kickers have few friends, and if 
the health officer’s bearing when under their attack is 
dignified and gentlemanly, other people will in time come to 
his rescue and rout them for him. 
The health officer must make all possible kinds of contacts 
with his community. Success depends largely on how well 
he is liked as a human being, as well as on the effectiveness 
of his work. Men who are in the work sometimes remark 
that they do not care what the public thinks of them per- 
sonally, provided they like their work. This attitude 
is absolutely wrong and dangerous. Unfortunately the 
great majority of people are not so constituted as to judge 
matters impersonally, and cannot divorce their estimate of 
the work done from their reaction to the personality of the 
man doing the work. Good advice is to “make friends” 
and above all to “mix,” especially to “mix.” 
In order to mix well and to gain friends, the health officer 
must consciously strive to improve his own personality and 
ability. He should read the local papers carefully to know 
what is going on in his community and to follow the trend 
of public opinion. He should also read steadily and 
broadly on general topics, and be able to discuss these 
intelligently but without controversy. If he has ideas only FINANCE AND MANAGEMENT 
29 
on his specialty people soon tire of him. The one track 
mind is always a bore. He should try to improve his power 
of self-expression, both in speech and in writing, through 
study and observation. The ability to speak and write 
simply and effectively, without frills or rhetorical effects, 
but sincerely and clearly, is a tremendous asset in any work. 
Outside contacts should be maintained, to receive inspira- 
tion and a knowledge of new practices and principles. 
Membership in the American Public Health Association is 
essential, and the health officer should, if possible, attend 
its annual meeting, even at a personal sacrifice. Most 
certainly he should attend every meeting of his state’s 
health officers’ association, and take an active part in its 
affairs. 
Perhaps some health officers will feel that their duties 
are too arduous and time-consuming to permit them to do 
all or even a small part of the things suggested in this chap- 
ter. The remedy lies in better organization of the work, 
in the development of whatever latent executive ability they 
have, the systematizing of routine work, and the delegation 
of as much detail as possible to subordinates. The day’s 
routine should be reduced to the simplest procedures and 
the shortest possible time, even if days or weeks of study, 
experiment and planning are required to accomplish the 
result. The health officer must have time to think, to plan, 
to direct, and above all, to build good will and community 
support. No matter how good a job, from a technical 
standpoint, he has done, he has failed unless his public likes 
the result and is willing to continue on a basis of adequate 
financial support. CHAPTER IV 
OFFICE AND CONTROL SYSTEM FOR SMALL 
HEALTH DEPARTMENTS 
The proper management of a local health department 
involves much record keeping. Part of it is required by- 
state regulations, which demand certain reports to be made 
to the state health authority at stated intervals. Beside 
such reports, a record must be kept of various activities 
of the department, for information of the health officer 
himself and for the information of the local governing 
authority and the taxpayers, who are properly entitled to a 
report of accomplishment. Such records have historical 
and comparative value over a period of years. 
But, aside from such, there are other and, from an admin- 
istrative viewpoint, more important records to be kept. 
Some operations must be controlled and routine simplified 
and standardized, to bring about certainty and definiteness 
of performance. A few examples will suffice. 
1. When Mrs. X’s small boy is isolated on account of 
measles, her first question usually is, “How long will he 
be kept home?” If the answer is “five days,” Mrs. X 
expects someone from the health department early on the 
sixth day to remove the placard and if no one appears, 
she is convinced that the health officer is either negligent 
or inefficient and she is correct, for if the health officer has 
the right kind of office system, such an incident, trivial to 
him, but of much moment to her, would not occur. 
2. Mrs. Y telephones to the health officer about an 
alleged nuisance which offends her. The health officer or 
30 OFFICE AND CONTROL SYSTEM 
31 
his inspector investigates and finds no cause for complaint, 
or finds that it is a matter for another official to handle. 
Nothing, however, is said to Mrs. Y, and nothing apparently 
is done about it; Mrs. Y, therefore, decides that the health 
officer is indifferent, or worse. If system were in effect in 
the local health office, Mrs. Y would be courteously 
informed as to the findings of fact and what action had 
been, or would be, taken, and if not, why not. 
3. Mr. Z has a dairy and his cows have been tested for 
tuberculosis, but the dairy inspector asserts that new cows, 
not tested, have been added to the herd. Dairyman Z 
denies this. The inspector repeats his assertion and hard 
words ensue. If a proper record of this dairy had been kept, 
there would have been such positive and definite identifica- 
tion made and recorded for each cow that no dispute could 
have occurred. 
In planning a control and record system for a small 
health office, the health officer should study his require- 
ments very carefully, before adopting any forms or spend- 
ing money for printing. The forms should contain every 
essential fact, and omit non-essential items. Forms should 
be simple, with items logically arranged in the order in which 
the data are most frequently or most conveniently obtained 
in the field. Stock sizes of cards or sheets are advisable, 
and as few sizes as possible should be adopted. Every 
required form can be printed on two, three, or at the most, 
four standard sizes, e.g., X 11" sheets and 4" X 6" 
cards as the best two sizes, with 6" X 8", and 3" X 5" 
cards, as supplemental. 
A few specimen forms are given in the appendix. These 
forms are in successful use in well-managed small health 
departments, and are presented, not as models, but as sugges- 
tions which will be helpful to health officers in planning 
their own forms. 32 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
The Communicable Disease Card. 
This card serves at once the several purposes of a record, 
a control, and an epidemiological investigation form, for all 
the usual communicable diseases. 
As soon as a report of a case is received, the disease and 
name and location of the case are entered on the card, and 
given a serial number. The card is then taken into the 
field and the epidemiological data and control measures are 
entered on it. The card is then placed in the current file, 
in the order of its serial number, with a signal, or signals, 
on it at the date point on the upper edge, to indicate the 
future action to be taken with the case. Various colored 
steel signals can be used to indicate different procedures. 
For example, inspection for release, release without inspec- 
tion, visit by the nurse, culture to be taken, report to be 
received from attending physician, etc. Each evening, the 
cards on which signals are set for the next day are listed 
under the kind of work to be done, and the next day’s 
routine thus planned, in part, for each member of the staff. 
In compiling monthly or weekly reports, or in statistical 
tabulations, the entire set of cards can be removed from 
the file, sorted easily and counted in as many categories as 
desired. 
If a record of “carriers” is kept, a duplicate card can be 
placed in a special “carrier” file. 
Births and Deaths. 
As soon as a birth or death certificate is received, it 
should be carefully examined by someone who is familiar 
with statistical procedure in connection with these records, 
and if any action or investigation is required in connection 
with the certificate, a slip of colored paper should be clipped 
to the certificate to call attention thereto. Several colors 
may be used, with a penciled memorandum. For example, OFFICE AND CONTROL SYSTEM 
33 
a birth certificate may come in with missing items; a red 
slip is attached with the numbers of the missing items 
noted thereon. Or, the given name may be omitted; a 
blue slip is attached and the supplemental report filled out 
and mailed to the person who can make the report. Or, if 
there is an error, a yellow slip is attached. When the 
certificate is complete, the colored slip is removed. In the 
meantime, the certificate is safely kept in the file. 
With death certificates, several points are important and 
must be checked up. For example, every stillbirth, and 
every death under one year of age, should be checked to 
find out if a birth certificate has been filed. Every death 
from a notifiable disease should be checked against the 
communicable disease reports. Missing items should be 
obtained arid errors corrected. Especially should the cause 
of death be scrutinized and, if not satisfactory, additional 
or corrected information must be secured. Undesirable 
or indefinite terms must be replaced by exact, definite 
and accepted causes of death. Certain causes of death, 
under some circumstances (e.g. nephritis or septicaemia 
in a woman of child-bearing age) must be queried for addi- 
tional information to enable an accurate classification to 
be made. Where any such points arise in connection 
with a death certificate, a colored slip should be clipped 
to the certificate and kept there until the data are com- 
plete and satisfactory in all respects, or the correspond- 
ing birth certificate or disease report is filed, as the case 
may be. 
In tabulating causes of deaths, it is an unnecessary 
refinement to use the complete International List of titles 
with small populations (say under 100,000). An abridged 
list of 26 titles can be substituted with great saving in time 
and in printing costs. Such a form is shown in the appen- 
dix, which can be printed on Xll" sheets and used 34 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
for classifying deaths by causes and by various groups, 
such as age, sex, nationality of parents, occupation, etc. 
Nuisances. 
Although relatively unimportant, nothing can make or 
break a local health department in the estimation of the 
public more quickly than the method of handling nuisance 
complaints. If attended to promptly and effectively, the 
public is pleased and believes that all of the work of the 
department is efficiently performed. If neglected or 
indifferently handled, the people are convinced that there 
is negligence, favoritism or worse. 
Usually two forms are required for this work; a record 
and a notification to abate. The notification should be 
simple and brief and made in duplicate by means of a car- 
bon, in case legal action should become necessary. Wher- 
ever possible the signature of the recipient of the notice 
should be obtained on the duplicate which is retained. 
The record form should be adapted to the receipt of com- 
plaints as well as to the finding of nuisances in the course of 
routine or special sanitary inspections. A space should be 
provided for recording the nature of the 
also the inspector’s findings of fact. 
A form which was devised to serve as a record and notice 
combined is shown in the appendix and has proved very 
useful. The name and address of the complainant are 
entered only in the duplicate (yellow) sheet. The office 
in which this form was used made it a practice never to 
divulge the name of a complainant; always to inspect the 
premises of the complainant before investigating the 
nuisance, and to refuse to act on anonymous complaints. 
This reduces complaints to a minimum of real grievances, 
and helps to keep the department clear of neighborhood 
squabbles. OFFICE AND CONTROL SYSTEM 
35 
Dairy Records. 
Six forms are advisable in the control of the milk supply. 
They are 
1. Application for a permit 
2. Permit 
3. Score card 
4. Laboratory record 
5. Cow record. 
6. Report to dairyman of laboratory results. 
If such is issued by the 
health officer. 
The application for a permit, and the report to dairyman, 
should be on a 3" X 5" card, which can be mailed as a 
postcard (the regular postcard size should be avoided in 
forms, on account of difficulty in filing). The permit 
may be printed on a 6" X 8" sheet. The score card is 
printed on 8X 11" sheets, as is also the laboratory 
record. The cow record is easily handled on 4" X 6" 
cards. Specimens of satisfactory forms are presented in 
the appendix. 
No method of scoring dairies that is free from objections 
has as yet been devised. In the opinion of the authors, 
the Bureau of Animal Industry Standard Card gives too 
much weight to factors of relatively little importance in 
the South and West, while the Woodward method of scoring 
is cumbersome in operation and not readily understood by 
either the dairyman or the public. For our own use, we 
have devised a modification of the B. A. I. card, which, 
while its logical defects are admitted, gives better results 
in practice. 
The dairy cow record card is made out at the time of the 
original inspection at the dairy and undoubtedly requires 
time and some skill. The time and effort are well spent, 
however. Additional cards are made out as new cows are 36 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
added to the herd. These records are unnecessary where 
the milk is pasteurized. 
Laboratory Reports. 
Reports on specimens submitted to the local laboratory, 
if positive, (and also copies of positive reports from the 
state laboratory) should be checked against the reports 
of communicable diseases. If a report on the case has 
not yet been received, a signal should be attached to the 
laboratory report until the case report comes in. 
Laboratory results should be transmitted as promptly as 
possible, preferably by telephone, followed by a written 
3" X 5" postcard form report by mail, as a confirmation. 
The laboratory record card should not be filed until the 
report is made. Reports of milk examinations should be 
mailed (on 3" X 5" postcard forms) to the dairymen. 
School Medical Examinations. 
Where physical defects are found in school medical 
examinations, it is a good plan to attach a signal to the 
record and remove it only when the defect is corrected or 
the child has left the community. 
Diary and Scrapbook. 
Every health officer should keep a diary or daily record 
of every event of any importance. This may well be on 
X 11" sheets in a looseleaf binder, which can be per- 
manently bound at the end of the year. 
A scrapbook record should be kept of all newspaper 
items and publicity concerning the health department. 
The health officer should also prepare and enlarge, as his 
experience increases, a looseleaf notebook of data of all 
kinds. This should be of handy pocket size for constant 
reference, and should contain digests of all state health OFFICE AND CONTROL SYSTEM 
37 
laws and regulations, local health and sanitary ordinances, 
differential diagnoses, and useful data on all kinds of health 
subjects. In time this will become a valuable help and the 
health officer’s constant companion. The sheets should 
be typewritten for clearness and compactness. 
Office Equipment. 
The effectiveness of a health officer’s work depends to 
a considerable extent on the efficiency with which his office 
routine and records are handled. The office equipment can 
materially aid or obstruct efficiency. 
The best desk is the so-called ‘‘efficiency” type of flat- 
topped desk, the drawers of which contain card files and 
X 11" files for current matter. A "desk organizer" 
for current correspondence is an excellent means of keeping 
the desk neat and clear of loose papers, while a tray in the 
middle drawer conveniently holds signals, map tacks, 
pens, pencils, clips, rubber bands and other necessary small 
articles. 
There should be a stack of letter files and card files, pref- 
erably unit-built, so that equipment can be added as 
required. This file should also contain the birth and death 
index. A substantial book case should be installed, to 
contain not only the health officer’s technical library, but also 
volumes of government mortality statistics, bound health 
reports, bound copies of birth and death certificates, etc. 
A series of maps of the county, city or district, preferably 
mounted on swinging map frames, is very desirable for 
spot maps. 
If possible, a duplicating machine for form letters and 
publicity, and a small hand-operated addressing machine, 
should be obtained, as these are great time savers if any 
considerable number of form letters or bulletins are sent out. 
The duplicating machine can also be used to prepare 38 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
office forms of some kinds. In small quantities, this is 
cheaper than printing. 
As a general rule, the average physician is not skillful in 
‘‘paper work” or the systematizing of routine. Many, in 
fact, seem to scorn and deliberately neglect it. But in a 
health office, system must be obtained and maintained, 
to accomplish results. The health officer of real ability 
will so organize his work that the routine is handled thor- 
oughly and effectively, with a minimum of effort and 
time. Unless he can do so, details will master him and 
draw him from his more important functions of planning 
and executing. A lack of system will result eventually 
in a lack of public confidence in the man and his work, as 
he will soon be recognized as inefficient. 
Purchasing. 
If the municipality or county does not have a 
purchasing agent, the health officer should exercise especial 
care in regard to making purchases. Wherever possible, 
bids should be asked from all firms selling the product 
desired, and the lowest bid accepted. It is a good plan to 
enter all bids received on 3" X 5" cards, giving the name 
and address of the bidder, the quantity bid on, the price, 
and the article, and to keep these filed for reference 
whenever additional amounts of that article are required. 
One will get better prices by following this method. 
It is advisable to call for bids from out-of-town firms, 
but they should be required to make their bids f.o.b. the 
health officer’s town, or else allowance must be made for 
freight, express or postage charges. Wherever the local 
merchants make a price equal to or lower than the outside 
bidders, they should be given the preference, and at 
times it is good policy to do so anyway, if the difference in 
price is only slightly in favor of the non-resident bidders. OFFICE AND CONTEOL SYSTEM 
39 
Accounting. 
Every health department should keep its own accounts, 
partly as a guide to enable the health officer to stay 
within his budget, or allotment of funds, and partly as a 
record for protection against charges of financial mis- 
management. The accounts should show in some detail 
for what purposes money has been expended. A useful 
classification is: 
A. Salaries and personal service. 
B. Transportation expense. 
C. Equipment. 
D. Printing and publishing. 
E. Postage. 
F. Telephone and telegraph. 
G. Express, freight and cartage. 
H. Office supplies. 
J. Laboratory supplies. 
K. Books, pamphlets, posters, periodicals. 
M. Films and lantern slides. 
P. Vaccines and antitoxins. 
S. Miscellaneous. 
This list can be changed according to local conditions, but 
for the average health department it gives about as much 
detail as is of material value. In large health departments, 
it is usually advisable to classify expenditures by function 
(administration, food inspection, sanitation, communicable 
diseases, child hygiene, education, etc.), as well as by 
purpose. 
In determining the accounts to be kept, someone with 
a thorough knowledge of accounting should advise the 
health officer in preparing the system, and in setting up 
the books. A looseleaf form is generally the most satis- 40 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
factory. There is available a wide variety of stock sheets 
which will give almost any amount of detail required. 
Every month the health officer should check up his 
accounts with those of the municipal or county auditor 
and should prepare a brief summary, showing the expendi- 
tures by purpose, for the month, and the total expenditures 
to date. CHAPTER V 
REGISTRATION OF BIRTHS AND DEATHS 
The process of registration of births and deaths is one 
by means of which certain facts in regard to each birth and 
death in a population group are recorded. From these 
recorded facts, by compilation and analysis, we obtain 
the vital statistics which enable us to measure the health 
of a population group and various demographic data of 
value to the sanitarian, the economist and the statesman. 
Birth and death registration is also of great importance 
from a legal standpoint. A birth record may be needed 
at some future time to 
Prove citizenship 
Prove right to vote 
Prove school age 
Prove age of consent 
Prove legal age for marriage 
Prove age under child labor laws 
Prove age for military service 
Prove right to hold public office 
Prove right to property inherited 
Prove nationality, in foreign countries 
Prove qualification for jury service 
Secure passports 
A death record may be needed to 
Establish property rights 
Establish insurance claims 
41 42 
ELEMENTS OF PUBLIC HEALTH ABMTNISTBATION 
Establish pension claims 
Establish legitimacy of children 
Settle inheritance claims 
Settle genealogical disputes 
It is for these reasons that all birth and death certificates 
should be treated as legal documents’, that every item should 
be faithfully and carefully filled out as far as possible; 
that full names, correctly spelled, should be given, and that 
only unfading ink should be used in their preparation. 
Having considered the general aspects of vital statistics 
in another chapter, we shall here concern ourselves only 
with the salient points of the process of registration. It 
is in the careful observance of many details that success 
in registration lies, for statistics are of value only in so 
far as the fundamental facts on which they are based are 
complete and accurate. The procedures outlined in this 
chapter are based largely on the standards advocated by 
the Census Bureau. 
The generally accepted method for registration of deaths 
is to require by law that no body may be buried, removed, 
or held more than a few hours pending final disposition, 
unless a permit therefor has been issued by the proper 
official. But, in order to obtain such permit, a death 
certificate must first be completely made out and presented 
to the official issuing the permit. Such an official is usually 
termed a “registrar,” or “subregistrar.” This simple 
procedure seems to cause considerable misunderstanding 
at first, wherever it has been introduced. Neither the 
public nor the registrars immediately comprehend the 
fundamental underlying purpose of the regulation. This 
is simply to insure the filing of a complete death certificate 
for every death. The means chosen as most effective is 
to make unlawful the disposal of a body without a burial REGISTRATION OF BIRTHS AND DEATHS 
43 
permit, for which permit the filing of a death certificate 
is pre-requisite. 
In order to make it entirely practicable for every death to 
be registered (and also every birth) provision is usually 
made for the establishment of subregistrars at points 
conveniently accessible to the general public. There should 
be a subregistrar in every school district or voting precinct 
outside of incorporated cities, towns, and villages, in order 
to make registration easily possible. 
In obtaining the facts which are required in order to 
accomplish satisfactory registration, certain duties are placed 
upon the various persons concerned with the case. It is 
the duty of the undertaker, or other person disposing of the 
body, to obtain the personal items called for on the death 
certificate. These items relate to the place of residence, 
age, sex, color, marital condition, occupation, nativity and 
parentage of the deceased. These must be obtained from 
the person best qualified to give the information, usually a 
relative, and the information should be given over the 
signature of the informant. 
The statement as to the date and cause of death is made 
by the attending physician, if any. Where the death occurs 
without medical attention, two procedures are available. 
If the death occurred under circumstances suggestive of 
foul play or suicide, an inquest must be held by a coroner 
or other officer acting as a coroner. In such case, the 
verdict of the coroner’s jury is entered as the cause of death, 
and attested by the signature of the coroner or person act- 
ing as such. In case the death was apparently by natural 
causes, but without medical attendance, the health officer 
is sometimes required to investigate the facts, and to 
certify over his signature as health officer the probable 
cause of death. This duty may fall upon the county or 
city physician. 44 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
The undertaker, or person disposing of the body, after 
having obtained the personal particulars and entering the 
date and place of burial or removal, presents the certifi- 
cate to the attending physician to enter the date and cause 
of death. With the certificate completed, he proceeds to 
the local registrar or sub-registrar and receives in return 
for the certificate a permit to bury, remove or otherwise 
dispose of the body. 
It is entirely possibe for the registrar to keep a close 
check on the regular undertakers, and secure the filing of a 
death certificate for every case handled by them. Almost 
invariably the undertaker will do his best to comply with 
the regulations. But the difficult part of the problem is 
securing certificates for deaths occurring in isolated areas 
without a regular undertaker in charge. Registration of 
stillbirths as deaths is also sometimes difficult to secure. 
There are several ways of seeing that the regulations are 
enforced, and a few suggestions are offered. The local 
papers usually report deaths, and a list of such deaths 
should be kept and used as a check. If the death certifi- 
cate is not received, an investigation should be made 
promptly. A few judicious prosecutions in cases where 
the regulations are violated will have a very salutary effect. 
Keeping track of the sale of caskets or coffins is another 
means of checking death returns. In some states every 
retail seller of caskets is required to enclose a blank death 
certificate and a notice giving the essentials of the law in 
each casket sold, and to make monthly reports of such 
sales to the state health department. By cooperation 
with the seller, these cases can be investigated promptly. 
Although it is important that the registration regulations 
be thoroughly enforced, it will be found advisable to use 
discretion in some cases. There are instances in which a 
literal interpretation of the regulations would cause great REGISTRATION OF BIRTHS AND DEATHS 
45 
difficulty without succeeding in getting better results than 
a more liberal interpretation would. It is sometimes advis- 
able, for example, in very sparsely settled areas, to let a 
responsible undertaker proceed with a burial, provided he 
first notifies the registrar, under his promise to file the 
death certificate on his return. When a twenty to forty 
mile trip is involved, this is reasonable. 
Birth registration presents in some ways more difficulties 
than death registration. At any rate, the death registra- 
tion, as a rule, is more complete than birth registration. It 
is easily possible to prohibit a body being buried without a 
permit, but not to prohibit children from being born with- 
out a permit. Yet it is possible to get a high percentage of 
birth registration. Newspapers serve as one source of 
information. In rural districts, the local postmaster, or 
school teacher, if properly approached, will cooperate in 
advising the health officer or registrar as to recent births. 
Baptismal records in churches can usually be seen if the 
priest or clergyman is courteously requested for permission 
to do so. And finally, it is worth while, say once in two 
or three years, to make a house-to-house canvass of the 
registration district, listing every child under one year 
of age, and then checking these against the registered 
births. 
Of course, every physician should be personally seen by 
the local registrar, and asked to cooperate in filing reports 
of births promptly. The physicians should be urged to 
carry blank birth certificates in their obstetrical bags, and 
to fill out the report before leaving the house in every 
confinement case. Particularly urge them not to wait for 
the parents to decide on the name of the child. The name can 
always be filed later, on a supplemental report of birth, 
but if the doctor waits for the name, he may forget to file 
the birth certificate. 46 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Midwives should be personally instructed as to the regu- 
lations and in making out the certificates, and it is a good 
plan to look over their record books at irregular intervals, 
as a check on their reporting. 
Every effort should be made to see that the public at 
large understands the principal requirements of the regis- 
tration regulations. Notices in local papers, slides in 
motion picture shows, posters, etc., are useful for this 
purpose. And an occasional successful prosecution of a 
persistent violator, prominently reported in the local papers, 
is especially effective in helping to bring about complete 
registration of either births or deaths. 
Complete birth registration is essential if the nurses of a 
health department are to be enabled to reach the mothers 
of young children and aid them to rear strong, healthy 
offspring. If the birth records are incomplete, the reduction 
of a high infant mortality is very difficult. CHAPTER VI 
VITAL STATISTICS 
That “no health department, state or local, can effectively 
prevent or control disease without knowledge of when, 
where, and under what conditions cases are occurring’’ 
is an axiom well known to all engaged in public health 
work. It is with such knowledge, gained from the col- 
lection and statistical study of reports of deaths and 
disease, as a guide, that the sanitarian lays his plans for the 
protection of the health of this community. It is through 
constant and careful study of these reports received from 
day to day that he keeps himself forewarned against 
impending epidemics. As one writer has said, “No light- 
house keeper on a rocky coast is charged with a greater 
responsibility than he who is set to watch for the signs of 
coming pestilence from the conning tower of the health 
department.” And, lastly, it is through the use of his 
“vital statistics”—the “bookkeeping” of public health— 
that the health officer is able to check up the results of his 
efforts and show, in a tangible way, what has been accom- 
plished in a given period. 
Unfortunately the study of vital statistics has not proven 
generally popular, on account of the tendency on the part of 
most people, especially those who do not like mathematics, 
to regard all statistics as “dry” and uninteresting. Statis- 
tics appear dry to an individual because he fails to visualize 
the things for which they stand. He looks upon a statis- 
tical table as a mere collection of figures, which, taken alone, 
are meaningless, and, of course, uninteresting. If, in the 
47 48 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
study of statistics, one will bear in mind that the figures 
are not mere figures alone, but that they represent certain 
vital things or events, he need not find them uninteresting 
at all. 
Another thing which has caused a lack of interest in 
statistics is the popular belief often expressed in the 
statement that “you can prove anything by figures”. The 
fallacy of this belief may be easily seen on a moment’s 
reflection. The statistical method consists simply in the 
expression of facts by figures, through mathematical proc- 
esses. If the figures are so manipulated as to produce an 
erroneous result, such result is not a fact, and any conclu- 
sion based thereupon is obviously no more dependable 
than one drawn from any other kind of faulty evidence. 
The health officer has also been handicapped in the 
obtaining of material for statistical purposes on account 
of the prevalence of the idea that the collection of records 
of births, deaths and disease is largely “red tape,” carried 
out by the health department as a time-honored custom, 
and that the material is to be filed away or used only for 
the preparation of formal reports. It is the purpose of 
this chapter to point out briefly how these records may be 
used through the statistical method in a practical way. 
There are two main sources of error to be guarded against 
in the making of vital statistics: the use of incomplete, 
inaccurate or improper data, and the employment of 
faulty methods in classification, compilation and analysis. 
It is for this reason that population enumeration, registra- 
tion of births, deaths and marriages and the reporting of 
notifiable diseases should be complete; that the records 
should be completely and accurately filled out, and that the 
health officer who would work out dependable statistics 
should acquaint himself beforehand with the methods of 
procedure involved. This does not mean, however, that VITAL STATISTICS 
49 
the local health officer must become a mathematical expert 
in order to be able to make practical use of his vital statis- 
tics. While many processes included in the statistical 
method involve elaborate and complicated mathematical 
procedures, practically all of the processes used in such 
statistical work as is within the limitations of the average 
small health department are quite simple and within the 
bounds of ordinary arithmetic. For a concise discussion of 
some of the more elaborate processes, the reader is referred 
to Whipple’s splendid hand-book on “Vital Statistics.” 
Vital statistics commonly include births, deaths, 
marriages and morbidity, or cases of disease. In com- 
paring the occurrence of these events in a given community, 
with that for another community, or for different periods 
of time, ratios to a given base, such as a unit of population, 
are used—that is, so many births per 1000 population, 
or so many deaths per 100,000, etc. These ratios are 
known as “rates,” hence the terms “birth-rate,” “death- 
rate” and so on. Since population is commonly used as a 
base for most birth, death, morbidity and marriage rates, 
it is essential that the health officer contemplating the 
preparation of vital statistics have an understanding of 
statistics of population. The reader will find the dis- 
cussion of this subject by Trask, in his paper on “Vital 
Statistics, A Discussion of What They Are and Their Uses 
in Public Health Administration,” quite useful in this 
connection. 
POPULATION 
The population figures generally used by health authori- 
ties for statistical purposes are those of the U. S. Census 
Bureau. As the federal census is taken only every ten 
years, however, it is necessary to “estimate” the popula- 
tion of a given community for intercensal years. This 50 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
may be done in two ways: by the arithmetical method, or 
by the geometrical method. 
The arithmetical method is based on the assumption 
that the increase or decrease in population which took 
place between the last two census years was spread evenly 
over the ten year period, and that the same annual increase 
or decrease will continue for the years following. For 
example, a city in 1910 had a population of 3G00, and in 
1920 a population of 4800. The total increase was 1200, 
or 120 a year, between 1910 and 1920. Therefore, by the 
arithmetical method, the estimated population for 1921 
would be 4920—4800 in 1920, plus an increase of 120 for 
the following year. The geometrical method consists 
in the use of the mathematical principle involved in the 
calculation of compound interest; that is, the increase of 
population for a given year may be determined by multiply- 
ing the yearly percentage of increase into the sum of the 
population at the beginning of the preceding year and the 
increase for that preceding year. 
Where the increase in population depends largely upon the 
excess of births over deaths, the geometrical method is the 
more accurate. The arithmetical method is more appli- 
cable when the increase is due to immigration. The arith- 
metical method has the advantage of being more simple 
and is the one most generally used in the United States. 
Where it is desired to determine which is the more accurate 
for use in a given community, one may take the last two 
intercensal periods and, by working out the rate of increase 
by both methods for the first period, determine which was 
more accurate in estimating the increase for the second. 
BIRTH STATISTICS 
While birth statistics alone have only a casual interest to 
the health officer, they are valuable to the community as a VITAL STATISTICS 
51 
whole in enabling it to determine its natural increase or 
decrease in population through the excess of births over 
deaths, or vice versa. Birth records are of importance, 
however, to the health officer in many ways, as will be 
shown in another chapter. The principal interest of the 
health officer in birth statistics is in the computing of the 
infant mortality rate, which is based upon births, instead of 
population. 
Birth-rates may be based upon population or on number 
of women of child-bearing age. The rate based upon 
population is the one generally used for comparison of one 
community with another, or of one year against another in 
the same community. The unit of population for this rate 
is 1000; that is, the birth-rate represents so many births 
per thousand inhabitants. The rate is determined, there- 
fore, by dividing the number of births for the period of time 
selected (usually a year) by the number of thousands of 
inhabitants. For example, a city with a population of 
4000 had 100 births in the year 1919. Dividing 100 by 4, 
we get 25, which represents the birth-rate for that year. 
To illustrate how birth-rates may be used for comparison, 
the following tables are shown: 
Table II—Birth Rates of Five 
Cities for a Given Year 
Table III—Birth Rates of 
a City for Five Years 
City 
Births per 1000 
population 
A 
30.1 
B 
27.5 
C 
25.0 
I) 
23.4 
E 
22.3 
Year 
Births per 1000 
population 
1916 
27.5 
1917 
27.0 
1918 
26.4 
1919 
25.2 
1920 
27.6 52 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
By means of Table II, the birth-rates for City A are 
compared with those of Cities B, C, D, and E for a given 
period. In Table III, the birth rates for a given city are 
compared over a period of five years. 
One important point to be remembered in computing 
birth rates is that stillbirths are not counted as either births 
or deaths for statistical purposes. 
DEATH STATISTICS 
Death or mortality statistics, like birth statistics, are 
of value to the community because of their relation to 
population growth. To the health officer they are of 
special interest, because of their value in showing the losses 
to his community from disease, thus enabling him to create 
public interest in health protective measures, and because 
of the means which they present for measuring the results 
of public health work, by showing the saving in human lives 
accomplished from year to year. The following tables 
illustrate how mortality statistics may be used in this 
connection: 
Table IV 
Table V 
Year 
Death rate 
City A 
Death rate, 
Registration 
Cities, U. S. 
1912 
20.0 
15.0 
1913 
19.6 
15.2 
1914 
19.7 
14.7 
1915 
20.5 
14.5 
Year 
Death rate 
City B 
1905 
22.0 
1910 
20.2 
1915 
17.2 
1920 
15.0 
In Table IV, the death-rate for City A is compared with 
that for all Registration Cities in the United States, showing 
the excess of loss of human life in City A over the average 
loss in other cities. We note that in 1912, City A hadjan VITAL STATISTICS 
53 
excess of 5 deaths per thousand; if this city had a popula- 
tion of 10,000, this means that the total excess in deaths 
was 50. The value of the average human life to the 
community is estimated roughly at $2000.00. It can 
therefore be shown that this excess of 50 deaths cost the 
community $100,000—several times the expense required 
for the maintenance of an adequate health department. 
In Table V, the reduction of the death-rate for City B 
over a period of 15 years is shown. In this way it is possi- 
ble for the health officer actually to see the results of his 
work for this period, provided the various factors affecting 
the death-rate are duly evaluated. 
Where dependable case reporting has been lacking, 
mortality statistics have been used as indices of the preva- 
lence of certain diseases. The variable case fatality rates 
often encountered, however, make this source of informa- 
tion generally unreliable. 
Death-rates, with the exception of rates for single diseases, 
are usually based upon a population unit of 1000. For 
example, a city of 10,000 inhabitants which had 150 deaths 
in a given year, would have a death rate of 15 per thousand. 
The rates for single diseases are usually based upon a 
population unit of 100,000, to avoid the use of fractions. 
What is known as the crude death-rate is the ratio of all 
deaths to the total population in thousands. This rate is 
applicable for comparison of the mortality for communities 
having populations of similar make-up as regards age, sex 
and race, but its use where the communities are not similar 
in these respects will lead to wrong conclusions. To over- 
come this source of error, we have what are known as 
specific death rates, and standardized or corrected rates. 
For a detailed explanation of these rates the reader is 
referred to Whipple’s book on “Vital Statistics.” Briefly, 
a standardized death rate is that rate which is obtained 54 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
when the actual deaths in the actual population are com- 
puted by special rates for the various age groups of that 
population, and then those special rates applied to age 
groups of a population of standard age distribution. The 
summation of the latter figures, divided by the total popula- 
tion in question, gives a standardized death rate, by means 
of which death rates in non-comparable populations may 
be compared with each other. 
Z/sa fra yn Mo./. 
,2£Z ! 
4gcs 
Migration, the birth-rate, marital condition of inhabi- 
tants and deaths of non-residents all affect the death-rate 
of a community. It is a common practice to exclude 
deaths of non-residents. As there is usually no means of 
including, in computing the death-rate for a registration 
district, deaths of residents which occurred outside such VITAL STATISTICS 
55 
district, the exclusion of non-resident deaths is an improper 
practice, especially in small districts. It is only admissable 
when the gross deaths and death-rate are exhibited first; 
then there is given a statement of what constitutes resi- 
dence and non-residence (the most satisfactory definition 
is that period required by statute to entitle a citizen to 
vote); the fact that deaths of residents occurring outside the 
registration district are not included; the number of deaths 
excluded as non-resident under the classification adopted, 
and, finally, the net deaths and net death rate are stated. 
The infant mortality rate is discussed to some extent 
in another chapter. This rate (representing the mortality 
of infants under one year of age), is based upon living births 
instead of population, the unit being 1000. The reason for 
this is the great difficulty encountered in the census 
enumeration of infants, especially as to age, which makes a 
population unit unsafe for use as a base. As an illustration 
of the method of determining the infant mortality rate, 
suppose we have a city in which 500 live births occurred in 
a given year, and in which there were 60 deaths among 
infants under one year of age. Since there were 60 deaths 
to 500 births, there would have been 120 deaths for 1000 
births; the infant mortality rate is therefore 120. Another 
means of comparison sometimes used in connection with 
mortality among children is that of separating out the 
deaths from diarrhea and enteritis among infants under two 
years of age. 
An important development of the use of mortality statis- 
tics has been the life table from which the expectancy of life 
at a given age may be obtained. As an indication of the 
progress which has been made in the conservation of human 
life within the past 40 years, it is interesting to note that the 
expectation of life has increased materially, especially 
in the lower age groups, during this period of time. 56 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
MORBIDITY STATISTICS 
The principal interest of the health officer in morbidity 
statistics lies in their usefulness in showing the prevalence 
of disease in his community, through which he is enabled 
to plan his work and to keep watch for outbreaks. Through 
the daily use of his morbidity reports, he is also able to 
institute proper control measures for each case as it occurs. 
The necessity for prompt and complete reporting is there- 
fore obvious. 
Since a large proportion of cases of notifiable diseases are 
never seen by a physician, the health officer, in order to 
obtain reporting sufficiently complete to give him depend- 
able information as to the true prevalence of disease in his 
community, must make every effort, through educational 
measures, toward developing the habit of voluntary report- 
ing on the part of the general public. As one writer 
has expressed it, “The requirements for notification of 
the preventable diseases and the extent of their enforce- 
ment may be taken as an index of the intelligence and 
efficiency of health administration in a community.” 
As to the practicing physician and the reporting of notifi- 
able diseases, one cannot do better than quote the words of 
Trask, in his paper previously referred to, “The physician 
is the one, who because of the very nature of his work and 
his relation to the community, is best able to have this 
information and furnish it. He comes in contact with the 
sick to a degree others do not. 
“Unfortunately many practicing physicians have little 
knowledge of the methods of health administration and in 
common with people in general frequently expect the health 
department in some mysterious manner to control disease 
without placing upon them the burden and privilege of 
cooperating by the notification of the occurrence of cases. 
The practicing physician, whether he recognizes it or not, VITAL STATISTICS 
57 
or is so recognized by the community, is essentially an 
adjunct of the health department, for unless he performs his 
part, the health department is in a large measure helpless. 
“Among practicing physicians, at least in the United 
States, there has at times been the feeling that the knowl- 
edge of a disease in a patient is privileged information 
which they should not be called upon to impart. In com- 
munities where the laws require the notification of disease 
this feeling has no legal basis and the physician who does 
not make reports is not a law-abiding citizen. But aside 
from the legal aspects of the matter there would seem to 
be little justification for such a course. Every physician 
has a number of individuals or families who look to him, 
and properly so, not only for treatment, but also for such 
reasonable protection from disease as he is able to give. 
The failure to report the occurrence of a case of communi- 
cable disease in one patient may lead to its spread to others 
among his clientele whose rights he has ignored. He 
therefore violates the intent and spirit of the ethical prin- 
ciple of the protection of patients among whom must be 
considered the well together with the sick. The notifi- 
cation of disease is in the interests and for the protection of 
the community, and as his patients are usually members of 
the community their interests are ignored and because 
of the anti-social whim or supposed convenience of the indi- 
vidual affected with a notifiable disease they are deprived 
of the protection they have a right to expect. It would 
seem that the physician who fails to report his cases of 
preventable diseases required to be notified may properly 
be considered as actively obstructing public health 
administration. ’ ’ 
The reporting of certain preventable diseases may be 
greatly facilitated indirectly by the use of the diagnostic 
laboratory. 58 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
For comparison, morbidity statistics, like death statis- 
tics, may be expressed as “crude” rates, or as “specific” 
rates. The crude rate expresses the ratio of cases of a given 
disease occurring during a given year, to a population unit 
of 1000, 10,000 or 100,000. The larger units are sometimes 
used to avoid fractions. The specific rate, usually based 
on a unit of 1000, shows the incidence of disease by age 
groups, sex, occupation and so on. In determining what is 
known as the “case fatality rate,” the ratio of the number 
of deaths from a certain disease to 100 cases is com- 
monly used; in other words, the mortality is expressed in 
percentage. 
An example of the use of morbidity statistics for com- 
parison is given in the following table: 
Table VI 
City 
Population 
Number 
cases 
Case rate per 
1000 popu- 
lation 
Number 
deaths 
Case fatality 
rate 
A 
10,000 
100 
10.0 
20 
20.0 
B 
20,000 
400 
20.0 
20 
5.0 
MARRIAGE STATISTICS 
Marriage statistics, compiled from records obtained 
through the registration of marriages in much the same 
manner as births and deaths are registered, have their 
greatest usefulness in the furnishing of information relative 
to social life, and the growth of population through births. 
For example, the number of married women of child- 
bearing age, in a community, is a determining factor 
in the birth-rate and may explain a difference between 
the birth-rates of two communities of equal population. 
In addition, the records are of legal value as evidences of 
legitimacy of children and the dower rights of women. VITAL STATISTICS 
59 
The marriage rate is commonly based upon population, 
the unit for the ratio being 1000, as in the case of births and 
deaths. 
It is hoped that the foregoing has given to the health 
officer an insight into the uses of vital statistics and some of 
the more common processes in their preparation. As 
Whipple has said, “Many of you have been in office a 
long time; you have forgotten most of your arithmetic— 
not to mention algebra. You can see the new era coming, 
and you dread the new methods founded on accurate 
statistical studies of accident, disease and death. There 
is no need of this fear You can use statistics as well as 
anyone, but you must study.” CHAPTER VII 
HEREDITY AND PUBLIC HEALTH 
The subject of heredity is one of the least understood, 
and yet probably one of the most important, of all of the 
factors involved in public health work. There has seemed 
to be on the part of health officials a tendency to avoid 
consideration of hereditary factors in public health. Yet 
it appears that only on the basis of heredity can we account 
for some of the facts in public health, and it seems probable 
that if we can utilize more effectively some genetic prin- 
ciples, we may be able to do more effective public health 
work. 
Let us take for first consideration the question of lon- 
gevity. A mass of data has been accumulated by the Gen- 
ealogical Record Office, by Karl Pearson and Mary Beeton, 
and by A. Ploetz. In figures given by the Eugenics Record 
Office covering 340 families in which the father or uncle 
lived to 90 years or more, there was a total of 2259 chil- 
dren, of whom 119 died before the fifth year of life. This 
would give an infant death rate of 53 per 1000 for the first 
four years of life, as compared with 400 for the Registration 
Area in 1880. In commenting on this astonishing figure, 
Popenoe and Johnson state, ‘‘If any city could bring the 
deaths of babies during their first twelve months down to 
53 per 1000, it would think it had accomplished the 
impossible; but here is a population in which 53 per 1000 
covers the deaths, not only in the fatal first twelve months, 
but of the following three years in addition. Now this 
population with an unprecedentedly low rate of child 
mortality is not one which had had the benefit of any Baby 
60 HEREDITY AND PUBLIC HEALTH 
61 
Saving Campaign, nor even the knowledge of modern 
science. Its mothers were mostly poor, many of them 
ignorant. They lived frequently under conditions of 
hardship; they were peasants and pioneers. Their babies 
grew up without doctors, without pasteurized milk, 
without ice, without many sanitary precautions, usually 
on rough food. But they had one advantage which no 
amount of applied science can give after birth—namely, 
good heredity. They had inherited exceptionally good 
constitutions.” Beeton and Pearson have found that the 
children of parents who died young have a higher infant 
death rate than the children of parents who are long-lived. 
In studying the daughters of mothers, they found that 
where the mothers died under 38 years of age, 52 per cent, 
of their daughters died in infancy, while for those mothers 
who lived to 84 or more, only 10.5 per cent, of the daughters 
died, the percentage diminishing steadily as the age-at- 
death of the mothers increased. A similar relation was 
found for the daughters grouped by the father’s age-at-death. 
Ploetz, in a study of child mortality in relation to the age- 
at-death of the father, in various royal and princely families, 
found that the percentage of children who died was greatest 
in the group where the father died young, and least where 
the father died at an advanced age. 
These facts are not only interesting in themselves, but 
are especially so in connection with recent statements and 
statistics prepared by the U. S. Children’s Bureau. This 
Bureau has presented a chart showing that infant mortality 
is highest in families in which the father’s wage is lowest. 
They say, “As the father’s income goes up, the infant 
death rate goes down,” and imply that poverty is the 
important cause of infant mortality. 
These two groups of data, therefore, seem to disagree. 
It is not our purpose to enter into an analysis of the matter, 62 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
as it would involve us at great length in a controversial 
question presenting many difficulties. Probably back of 
poverty lie certain hereditary factors which have not been 
wholly taken into account by the Children’s Bureau. 
It would seem that both heredity and environment enter 
into the problem of infant mortality, and that we shall not 
be able to obtain the most effective preventive measures 
against it, unless we learn what these hereditary factors 
are and try to turn them toward the prevention of infant 
deaths. 
There is another interesting side light on the question of 
longevity and heredity. There are marked differences in 
death rates between various races and nationalities, which 
perhaps may be partly accounted for by different environ- 
mental conditions, but probably also are dependent in 
considerable degree on certain hereditary characteristics 
of the racial stock. This is indicated by the fact that 
there is a materially lower death rate among whites than 
among negroes, both living under the same general environ- 
ment in this country, and by the fact shown in statistics 
gathered by the U. S. Children’s Bureau that there are 
material differences in the infant mortality rates of vari- 
ous nationalities living under the same environmental 
conditions. 
Turning now to the question of the relation of heredity to 
resistance to disease, we find a number of facts of striking 
interest to the health officer. There seems to be valid 
evidence that man in his experience with disease undergoes 
an evolution in which the non-resistant strains are killed off, 
gradually leaving only those stocks which are more or less 
immune. A study of some English statistics will show this 
evolution at work. We select English figures because they 
have had excellent death registration running back for 
several generations. Typhus fever is a good example. HEREDITY AND PUBLIC HEALTH 
63 
This disease was a terrible scourge in past times, but is 
now seldom met with in more advanced countries. The 
deaths from typhus in England and Wales are as follows 
(as given by Brend): 
1869 
4281 
1876 to 1880 
. . . . 887 
1870 
3297 
1881 to 1885 
.... 603 
1871 
2754 
1886 to 1890 
.... 181 
1872 
1864 
1891 to 1895 
.... 106 
1873 
1838 
1896 to 1898 
. . .. 56 
1874 
1762 
1899 to 1906 
. . . . 39 
1875 
1499 
1907 to 1914 
. . . . 11 
Table VII 
The role of the louse in the transmission of typhus was 
not discovered until 1909, and even today bodily lousiness 
is quite prevalent in many quarters, yet typhus has almost 
vanished in England. 
For another example, take the case fatality rate in scarlet 
fever, expressed in percentages of deaths as compared with 
cases. The data are from the Metropolitan Asylum Board 
Records in England (Brend): 
1875-79 
. . . . 13.5 
1886.. 
9.0 
1893... 
. 6.1 
1880 
.... 12.3 
1887.. 
9.5 
1894... 
. 5.9 
1881 
. . . . 11.1 
1888.. 
9.9 
1895... 
. 5.4 
1882 
.... 10.4 
1889.. 
8.9 
1896... 
. 4.3 
1883 
. . .. 12.4 
1890.. 
7.9 
1897... 
. 4.1 
1884 
12.3 
1891.. 
6.7 
1898... 
. 4.1 
1885 
. ... 9.5 
1892.. 
7.3 
1899... 
. 2.6 
1900 
. 3.0 
1908 
. 2.6 
1901 
. 3.8 
1909 
. 2.3 
1902 
. 3.4 
1910 
. 2.3 
1903 
. 3.1 
1911 
. 1.9 
1904 
. 3.4 
1912 
. 1.6 
1905 
. 3.3 
1913 
. 1.2 
1906 
, 2.9 
1914 
. 1.2 
1907 
, 2.8 
Table VIII 64 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Concurrently with this decrease in the case fatality rate, 
the death-rate from scarlet fever declined from about 96 
per 100,000 in 1866-1870 to 6.3 in 1910-1914. There has 
been no specific remedy found for scarlet fever, such as 
antitoxin, and there has been practically no change in 
the management of the disease, so that this considerable 
decrease in its fatality must be due to something else. 
It seems most probable that this something else is the 
elimination of the non-resistant strains, leaving us a stock 
which has undergone an evolution by natural selection 
against the disease. The only other explanation that is 
immediately apparent as a possibility is that the infecting 
organisms may be suffering a retrograde evolutionary 
process. 
The same thing seems to be true to a considerable extent 
of tuberculosis. The decline in the tuberculosis death rate 
began long before its germ was demonstrated, and the rate 
of decline was almost as great before as since modern con- 
trol measures were instituted. There was a marked reduc- 
tion in the tuberculosis death rate of Edinburgh following 
the introduction of a dispensary system, but in the same 
period the death rate in Aberdeen, without a dispensary 
system, fell more rapidly. Pearson says, “It seems to 
me that when we study the statistics of the fall of the phthi- 
sis death rate, when we notice this fall taking place in 
urban and rural districts, when we see that it started long 
before the introduction of sanitorium and dispensary work, 
and that it has not been accelerated by modern increase 
of medical knowledge, then we are compelled to regard that 
fall as part of the natural history of man rather than 
as a product of his attempt to better environment.” 
There are other diseases which have either been practi- 
cally eliminated or have suffered a decline in virulence, 
apparently with little reference to man’s attempt to bring HEREDITY AND PUBLIC HEALTH 
65 
this about. Leprosy is of course an example. Syphilis 
today is not the acute disease it once was. 
But if there is evidence that a continued racial experience 
with a disease tends to select that race on the basis of the 
survival of resistant stocks, there is also another side of the 
picture. What about the aboriginal stocks in contact 
with the white man’s diseases? What about the white 
races in contact with unfamiliar tropical diseases? If 
heredity, that is racial experience with and selection against 
a disease, is a real factor in its prevalence and virulence, we 
should expect that racial stocks in contact with a strange 
disease would exhibit especially high death rates. And 
that is exactly what happens. There is nothing mysterious 
about the disappearance of the American Indians. They 
died because of inability to resist the white man’s diseases, 
rather than from wars or civilization. Tuberculosis is more 
prevalent among the negroes in the United States than the 
whites (432 to 170 in Registration Area in 1910). Wher- 
ever tuberculosis has encountered the colored races in 
Africa, in the South Pacific Islands, in Tasmania, it has 
been an acute and rapidly fatal disease. Even whole 
peoples have been wiped out, and entire districts depopu- 
lated, by the white man’s diseases, diseases to which the 
white man has become racially rather resistant by centuries 
of experience, but against which the aborigines had no 
protection of racial tolerance. The white man entering 
tropical countries finds himself severely attacked by diseases 
to which the native races are more or less tolerant, such as 
malaria, yellow fever, and the relapsing fevers. Now that 
we know the modes of transmission of these diseases, we 
are making it possible for the white man to live in and to 
develop the tropics, but we have not so far been able artifi- 
cially to develop his resistance to such diseases. (Note: 
Noguchi’s yellow fever vaccine is now being tried out 
extensively and gives great promise.) 66 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
In a number of diseases sanitation and medicine have 
accomplished marked results. The reduction of typhoid 
may be safely attributed in great part to safer water sup- 
plies and better sewage disposal. The reduction of diphtheria 
through antitoxin is a triumph of applied bacteriology and 
immunology. By applying hard-won scientific knowledge, 
we are now in a position to wipe out malaria and yellow 
fever, and can control, or practically eliminate, many other 
diseases. We have become able so to effect our environ- 
ment as to triumph over unfavorable outward conditions 
of life, but have become so absorbed in this work as to have 
neglected the important field of heredity. Our health 
problem in respect of many communicable diseases is 
really to study the methods of nature in combatting such 
diseases and then to aid and accelerate the process. For 
example, now that we know the means of spread of yellow 
fever, we can accomplish in a few years what it would take 
nature perhaps centuries to do. 
There is much to be learned about heredity, and much 
which can be learned which will be of great help in formulat- 
ing rational health procedures. As yet our knowledge is 
meager, but it is being extended. Perhaps in a few genera- 
tions we shall see radical changes in our methods as a result 
of a better understanding of the laws of heredity, and the 
adaptation of these laws to the problems of public health. 
We shall continue and intensify our attack on unfavorable 
environmental conditions, which has already produced 
signal results, but we shall also work with the hereditary 
factors and probably achieve an even greater success in 
promoting the public health. 
An important contribution to this subject has recently 
been made by Raymond Pearl in “The Biology of Death.” 
Every health officer should own this book and digest it 
thoroughly. CHAPTER VIII 
THE PROBLEM OF MATERNAL MORTALITY 
Recent investigations by the Federal Children’s Bureau 
have developed some interesting facts in regard to the 
great lack of adequate prenatal and obstetrical care. These 
conditions seem to be more acute in the rural districts than 
in the cities, on account of the isolation and distance from 
skilled medical attendance, but even in cities their impor- 
tance is apparently insufficiently appreciated. 
Too frequently, the physician, if called at all, is sum- 
moned at the last moment. No pelvic measurements, 
urine analyses, blood pressure readings, or other measure- 
ments and examinations have been made. He has nothing 
to guide him and must meet the situation as best he can. 
Obviously, under such circumstances, it is impossible for 
the physician to give the best attendance of which he may 
be capable, or to avoid unforseen complications, such as 
eclampsia. On the other hand, if all pregnancies were 
attended by careful physicians for several months, prior to 
confinement, many dangers might be eliminated or reduced 
and the woman, by hygienic supervision, placed in better 
physical condition to give birth to a normal, healthy child. 
As yet, a very considerable number of women, especially 
among the foreign born groups, do not call physicians, but 
employ midwives. These midwives are very seldom indeed 
trained in their work and are often dirty, ignorant and care- 
less. In fact, we may say that they are universally so, 
unless under the supervision of the State. There has been 
much discussion of the problem of the midwife in recent 
67 68 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
years, some arguing for her abolition and others for her 
regulation and training. At the present time, abolition 
seems impracticable, if not impossible, and the best solu- 
tion seems to be to place the midwife under state supervi- 
sion and regulation and to establish minimum standards 
to which she must conform in her practice. 
These standards are enforced by public health nurses or 
medical inspectors. New York and New Jersey, in particu- 
lar, have made notable progress along such lines. 
There is also a considerable number of births that receive 
practically no attendance, except that given by the father 
or by neighbor women. In the isolated rural districts 
this is far more often the case than in the towns. 
Very little information is available in respect of the causes 
of stillbirths, but there is little question that better pre- 
natal and obstetrical care, with more adequate measures 
for the control of syphilis, will reduce their number. This 
is a problem which should be more thoroughly investigated. 
The fundamentals for better prenatal care seem to be the 
following: 
1. Educational activities to acquaint all women with the 
importance of early and continuous medical attendance 
during pregnancy and at confinement. 
2. A campaign among physicians to raise the standards of 
prenatal care. Too much of this work is perfunctorily 
performed and insufficient tests and measurements are 
made. 
3. Legal authority should be given for the supervision 
and regulation of midwives by the state. This should be 
made effective by means of medical inspectors and super- 
visory nurses. 
4. Provisions should be made so that no woman, by 
reason of poverty or isolation, is compelled to do without 
adequate prenatal or obstetrical care. THE PROBLEM OF MATERNAL MORTALITY 
69 
Apparently we have made no progress in reducing mater- 
nal mortality, as the following tables show: 
Table IX—Death Rate of Mothers per Thousand Births 
(From American Child Health Association, 1923) 
Country 
Rate 
per 
1000 
births 
Country 
Rate 
per 
1000 
births 
Denmark 
2.4 
Germany.. 
4.9 
The Netherlands 
2.4 
Australia 
5.0 
Sweden 
2.5 
New Zealand 
5.1 
Italy 
3.0 
Spain 
5.2 
Norway 
3.0 
Ireland 
5.5 
Uruguay 
3.4 
Switzerland 
5.5 
Japan 
3.8 
France 
5.7 
England and Wales 
3.9 
Scotland 
6.2 
Hungary 
4.0 
United States 
6.8 
Finland 
4.4 
Table IXa—Maternal Mortality U. S. Registration Area 
Year 
Death rate per 100,000 
The puerperal state 
Puerperal septicaemia 
1910 
15.7 
7.2 
1911 
16.0 
7.4 
1912 
15.0 
6.5 
1913 
15.8 
7.2 
1914 
16.0 
7.1 
1915 
15.2 
6.3 
1916 
16.3 
6.8 
1917 
16.6 
7.0 
1918 
22.2 
6.5 
1919 
17.0 
5.8 70 
ELEMENTS OF PUBLIC HEATLH ADMINISTEATION 
Whether the reduction in puerperal septicaemia since 
1917 is a definite downward trend, or merely a temporary 
fluctuation, cannot be determined until official figures are 
available, but there is hope that the greater attention 
focused on this problem in recent years may make it possible 
to hold this gain and possibly improve on it. At any rate, 
a beginning has been made, on a national scale, in attacking 
the entire problem of maternal and infant mortality. CHAPTER IX 
MEASURES FOR THE PREVENTION OF MATERNAL 
AND INFANT MORTALITY 
Years of agitation and propaganda have finally suc- 
ceeded in forcing the passage by Congress, in 1922, of the 
Sheppard-Towner Bill giving federal aid to the several 
states in providing for better care of maternity and infancy. 
Originally conceived on broader lines, the bill was cut 
down until, as finally passed, it provided for but little 
beside educational measures. This much, however, if 
intelligently directed, cannot fail to have a marked and 
cumulative effect, for in the education of mothers we have 
one of the strongest weapons with which to reduce a high 
infant and maternal mortality. 
Continuous, unceasing, well-directed education on the 
hygiene of maternity and infancy is the one measure which 
is always applicable, always useful, and available under all 
conditions. The form of this education can and must be 
varied according to the character of the locality and of the 
people to be reached, but in some form it can always be 
used. Some of the methods are: 
(a) Distribution of printed or mimeographed advice and 
instructions, in the language of the group to be 
reached. Obviously this can only be used among 
the literate. A number of states and cities make 
a practice of sending printed matter to the 
mother of every child whose birth is recorded, as 
well as using other channels of distribution, such 
r as women’s clubs. 
71 72 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
(b) Newspaper publicity and press articles. 
(c) Newspaper and outdoor advertising. This is effec- 
tive if well done, but seldom used on account of 
the cost. 
(d) Visual education by means of motion pictures and 
lantern slides. This is no longer limited to towns 
and cities, as portable motion picture projectors 
and stereopticons are available, which can be 
operated on storage batteries, and so carried to 
remote rural districts by automobile. 
(e) Demonstrations in classes by public health nurses. 
(/) Individual home visits and demonstrations by public 
health nurses. 
The care of the child should begin before birth, and for 
that reason prenatal work should be an integral part of 
the health department’s child hygiene program. In cities 
prenatal clinics can be organized, to which the public 
health nurses can bring cases for examination and 
instruction. In the rural districts, however, reliance must 
be placed primarily on the nurse, who will locate the pre- 
natal cases and advise them as to the hygiene of pregnancy 
and the preparations necessary for confinement. She will 
also endeavor to have the proper examinations, measure- 
ments and analyses made by the attending physician, if 
one is available, or by the county health officer. 
The problem of adequate care at, and subsequent to, 
childbirth, in the rural districts, especially in the western 
states where distances to a physician are often great, is a 
difficult one indeed. Part of the difficulty can be overcome 
if adequate prenatal instruction has been given, so that the 
necessary preparations are made. In many of the isolated 
communities there are not even regular midwives available, 
but the obstetrical work is done by neighbor women. If 
the public health nurse can teach these women in PREVENTION OF MATERNAL AND INFANT MORTALITY 
73 
classes, as is being successfully done in some places, a great 
deal can be accomplished. At least some of the danger of 
puerperal septicaemia can be avoided; the imperative 
need of medical assistance, no matter what the distance or 
cost, in abnormal cases, can be made known; arrangements 
made for the use of an ophthalmia prophylactic, and 
some kind of sterile dressings for cord and perineum 
demonstrated. 
After birth, the public health nurse can follow-up 
the infant’s progress, aiding the mother with instruction and 
advice as to the child’s care. In towns and villages well- 
baby clinics, held at definite times, can be organized, so as 
to obtain this result with a minimum expenditure of time on 
the part of the nurse and health officer. 
A particularly fruitful field is the organization and 
instruction of “Little Mother’s Classes” among young 
girls, especially those who assist their parents in the care 
of the younger children of the family. The instruction in 
such classes begins with the care of the baby, and can be 
extended to the instruction of the older girls in the hygiene 
of pregnancy, and under favorable conditions, in sex 
hygiene. Home economics classes in the public schools fre- 
quently offer good opportunities for such teaching. 
The health department’s work in improving the milk 
supply is a decided factor in infant hygiene. After 
the infant is weaned, probably diet is the most important 
single factor in its welfare. If a safe, clean milk supply, 
of low bacterial count, is available, an important step in the 
reduction of infant mortality has been taken. It must be 
backed up, to be effective, by adequate instruction of the 
mother, preferably by the family physician, as to the proper 
diet for the infant. If no physician is available, the health 
officer, or public health nurse, should give careful feeding 
directions. 74 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Sanitation also plays a part. Mothers should be 
instructed as to the necessity for clean surroundings, for the 
reduction of flies through elimination of their breeding 
places and of the places from which they can derive 
infection, and as to proper ventilation. They should also 
be impressed with the need for proper care of soiled diapers, 
as this has been shown to be a potent factor in summer 
diarrheas. Levy, of Richmond, Va., produced a further 
reduction in infant mortality by this one procedure alone. 
In towns and villages health departments can take more or 
less direct action to bring about better sanitation. In the 
rural districts, however, education and persuasion are 
usually the only means available to improve sanitation. 
The health department should know, and keep in touch 
with, the various social and philanthropic agencies, such as 
hospitals, foundling and orphan homes, day nurseries, 
Associated Charities, Red Cross, Salvation Army, clinics, 
and all other organizations which can in any way handle or 
assist the abnormal cases which come to its attention. It 
is often the case that one of these agencies can solve a special 
problem that is outside the purview of the health depart- 
ment, and which it is not equipped to handle. By coordi- 
nating all such agencies with the health department, 
children’s lives may often be saved, or their health protected 
from impairment. 
A list of all the social and philanthropic organizations 
within his jurisdiction, with full data as to the type of work 
they do, their resources and personnel, should be in the 
possession of every health officer, and he should be person- 
ally acquainted with at least the executive officer of each 
one. CHAPTER X 
INFANT HYGIENE 
Many are the platitudes expressed by various writers 
regarding the value of infant hygiene work to society. 
These are indications of the great importance of the sub- 
ject. But from the standpoint of efficiency in public 
health procedure too few health officers even now realize 
that the employment of measures for the improvement 
of infant hygiene represents perhaps the quickest, most 
direct and most effective means of reducing the general 
death-rate of a community or a nation. The opportunity 
which exists may be seen by examining the death-rates and 
causes of death for the different age groups. The figures 
for the U. S. Registration Area, for 1911 and 1920 (two 
years of or near census years, so that the age groups are 
fairly exact) are as shown in Table X. 
The age groups which show the highest mortalities are 
seen to be those at either end of the span of life. A 
moment’s reflection will show that it will be a long, slow 
process to reduce the death rates in the highest age groups 
(over 45), as both the hereditary and environmental factors 
which affect these rates have largely become past history 
for such age groups, and are beyond our power to modify 
greatly. Whatever we may now do to affect such factors 
in the lower age groups will not be expressed in lower death 
rates in the higher age groups for many years, perhaps for a 
generation or more. In the age groups 10-35, the death 
rates are already very low, and it would obviously be some- 
what ineffective to direct our greatest efforts at a point 
75 76 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Age 
Deaths per 1000 of stated age 
1911 
1920 
Under one year.... 
112.9 
96.7 
2-4 
11.8 
6.5 
5-9 
3.1 
3.0 
10-14 
2.2 
2.3 
15-19 
3.6 
4.1 
20-24 
5.2 
5.7 
25-34 
6.4 
6.9 
35-44 
8.9 
8.3 
45-54 
13.6 
12.2 
55-64 
26.2 
23.9 
65-74 
55.2 
52.7 
75-84 
117.4 
85-94 
138.9 
237.0 
95 and over 
331.5 
Table X—Age Group Death Rates 
(See also Diagram No. 1.) 
where, naturally, the lowest mortality occurs. Therefore, 
by elimination, we turn to the earliest ages of life as the 
logical point at which to apply our greatest energies. 
An examination of the causes of death in the early age 
groups will throw further light on the subject, using again 
the figures for the U. S. Registration Area for 1911 and 
1920. 
In the first three groups, Diarrhea & Enteritis, Diseases 
of the Respiratory System, and Communicable Diseases, 
a priori reasoning and practical experience indicate that 
material results may be obtained by a reasonable effort 
and expenditure. For these affections are to a considerable 
extent the result of environmental, rather than hereditary, INFANT HYGIENE 
77 
factors, and so are more easily within our power to modify 
favorably. 
Table XI—Per Cent of Deaths under One Year of Age for Various 
Causes 
U. S. Registration Area 
Cause of death 
1911 
1920 
% 
% 
% 
% 
1. Diseases of the digestive system 
28.6 
20.1 
(a) Diarrhea and enteritis 
25.2 
17.6 
(b) Other diseases of the digestive system.. 
3.4 
2.5 
2. Diseases of the Respiratory System 
15.1 
15.5 
(a) Broncho pneumonia 
7.1 
9.2 
(6) Pneumonia 
4.9 
3.8 
(c) Acute bronchitis 
2.4 
2.0 
(d) Other respiratorv diseases 
0.7 
0.5 
3. Communicable diseases 
9.4 
12.5 
(a) Whooping cough 
2.5 
3.5 
(6) Tuberculosis (all forms) 
1.7 
1.2 
(c) Syphilis 
1.2 
1.1 
(d) Measles 
0.9 
1.1 
(e) Diphtheria 
0.6 
0.5 
(/) All other communicable diseases 
2.5 
5.2 
4 Diseases of early infancy 
36.6 
42.0 
(a) Premature birth 
15.8 
22.0 
(b) Congenital debility 
10.0 
5.4 
(c) Malformations 
5.3 
7.1 
f> Oilier miscellaneous causes 
10.3 
9.9 
Total 
100.0 
100.0 
(Note: Stillbirths npt included in this Table.) 
Diarrhea & Enteritis, for example, in general may be 
prevented, or their incidence much reduced, by attack 
along the two main lines of improvement in infant feeding 78 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
and sanitation. In the first line of attack we may (a) 
substitute proper for improper food; (b) improve the 
quality of food, and (c) improve its home preparation and 
regimen, (a) and (c) are largely matters of education of 
mothers as to what is the proper diet for infants, while (b) 
is to a considerable extent a function of the milk and food 
inspection divisions of health departments. Under (a) 
the encouragement of breast feeding is of importance, as 
available statistics indicate that a breast-fed baby has 
several chances to live as compared with the one of a bottle- 
fed baby. In the second line of attack, sanitation, measures 
for the reduction of flies and sanitary excreta disposal 
are demanded, as there seems to be little doubt that 
many intestinal disorders are transmitted by flies, where 
conditions are insanitary. An important detail, as has 
been shown by Levy in Richmond, Virginia, is the proper 
care of diapers, to prevent access by flies to fresh infective 
material. 
Under Diseases of the Respiratory System, possibly a 
part of the reported pneumonia and broncho pneumonia is 
really secondary to infections such as measles and whooping 
cough, and is not properly classified owing to the failure of 
the attending physician to enter the primary cause of 
death on the certificate of death. But aside from such 
cases there is reason to believe that much of the pneumonia 
could be prevented by hygienic measures. It would seem 
entirely possible, by means of education of mothers in 
hygiene; by increasing the vital resistance of infants; by 
reducing overcrowding, and by better care during and after 
acute contagious diseases, to cut down materially the 
death rates from these causes. 
Of the Communicable Diseases, whooping cough is the 
great baby killer, followed by tuberculosis (all forms), and 
syphilis. We are gradually developing more effective INFANT HYGIENE 
79 
measures against syphilis. There is hope that some day 
the really effective measures against tuberculosis (reduction 
of propagation of the non-resistant stocks, and protection 
of infants and young children from infection by tubercular 
adult relatives and friends, and by milk from tubercular 
cows) will be made an effective part of the anti-tuberculosis 
campaign. But against whooping cough we have made no 
progress, to our great discredit. The public still says 
“It is only whooping cough.” Long ago we should have 
instilled in the public mind a wholesome respect for pertus- 
sis, which kills far more than scarlet fever, and practically 
as many as diphtheria. It is never too late to campaign 
actively against pertussis; isolating the sick, quarantining 
susceptible contacts, and searching for mild and atypical 
cases. It seems probable that a more liberal use of pertus- 
sis vaccine as a prophylactic for contacts may be advisable, 
as its use in this manner, while still experimental, seems 
rather promising of good results, at least in modifying the 
severity, even if it does not always prevent the incidence, of 
the disease. The use of pertussis vaccine seems to be 
without danger, and it is advisable to try it out on a larger 
scale under practical conditions. Freshness of the vaccine 
is imperative and large doses should be given. The course 
for an infant can be two billion killed bacilli for the initial 
dose, followed by a four billion and a final four billion dose, 
given approximately seven days apart. 
Diphtheria and measles do not, in this age group, become 
a significant factor in mortality. 
Another measure for the prevention of communicable 
diseases is the education of parents to avoid the exposure of 
children to such diseases, either deliberately or accidentally. 
Some have a mistaken idea that children should have many 
of the common contagious diseases at an early age, and 
deliberately expose them to known cases. Mortality statis- 80 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
tics show that the longer infection is postponed the less is 
the mortality rate. 
The fourth main group of causes of death under one year 
of age is named “Diseases of Early Infancy,” and is made up 
of general causes termed “Premature Birth,” “ Congenital 
Debility” and “Malformations.” This group causes the 
largest percentage of deaths under one year of age. So far 
we have made little progress in combatting deaths from 
these causes. It is a singular characteristic of deaths in this 
group that their rates do not vary greatly under different 
social or environmental conditions. In other words there 
seems to be a fairly constant rate of birth and death of 
congenitally weak, malformed and unfit-to-survive infants. 
What the reason for this may be, whether ill-matched 
matings, or a hereditary factor, or purely fortuitous cir- 
cumstance governed by the law of chance, we cannot say; 
statistics are not available to guide us. The safest and 
most logical position to take, at present, is that better 
prenatal and obstetrical care should be encouraged by 
health departments, as hopeful of reducing both maternal 
and infant mortality, and as a measure of social value. 
But we should be careful not to promise great death rate 
reductions, as yet. 
In the final group of miscellaneous causes of death there 
are a number of causes which probably may be reduced by 
various measures; no doubt education of the mother in the 
care of her child will help to this end. 
This brief examination indicates that while there are 
certain important things which the health department 
may do favorably to influence the environmental factors 
which bear on infant mortality, nevertheless the thing of 
greatest importance is the intelligent care of the child by 
its mother. In other words, education of the mother in 
infant hygiene is probably the greatest single weapon in INFANT HYGIENE 
81 
the fight for the reduction of deaths from causes 1, 2, 3, 
and possibly 5. 
It is not, however, practicable to bring the mother to the 
education, as we bring the child to school. The responsi- 
bilities and cares of the household usually stand in the way. 
The instruction must be brought to the mother to be 
effective. This is the work of the public health nurse, or 
the child hygiene nurse, or the infant welfare nurse. Call 
her what you will, she is probably the most significant 
single factor in the modern health department. A poster 
entitled “A Health Department Without Nurses Is No 
Good,” displayed at the 1918 meeting of the American 
Public Health Association, was guilty of but slight 
exaggeration. 
The public health nurse brings to the mother direct, tangi- 
ble demonstration of proper measures for the care of her 
baby, not theoretical or book instruction. She shows the 
mother not only how to avoid bad methods of child care, 
but demonstrates good methods, and does so under the actual 
conditions existing in the home, not under the ideal conditions 
found in a well-equipped clinic. She often helps to undo 
the mother’s mistakes by giving the sick child proper care 
under the direction of the family doctor or the municipal 
physician, but this is a secondary feature of her work, for 
she cannot do daily sick-bed nursing without neglecting 
her more important educational work. This does not refer 
to bedside demonstrations in nursing care, for these are 
a very necessary part of her duties as a teacher. 
In the notable reductions in infant mortality which have 
been accomplished in recent years, the public health nurse 
has borne an important and essential part. As evidence of 
what has been accomplished, the following figures are 
suggestive: 82 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Table XII—Infant Mortality Rates 
Year 
New York City 
New York State 
exclusive of 
N. Y. City 
U. S. Reg. Area 
1904 
162 
134 
1905 
158 
137 
1906 
154 
140 
1907 
145 
139 
1908 
128 
136 
1909 
130 
126 
1910 
126 
135 
1911 
112 
118 
1912 
105 
114 
1913 
102 
120 
1914 
94 
105 
1915 
98 - 
100 
100 
1916 
93 
96 
101 
1917 
89 
94 
94 
1918 
92 
104 
101 
1919 
82 
74 
87 
1920 
85 
87 
86 
1921 
17 
81 
The figures just presented give the “infant 
mortality rate.” This is the number of deaths under one 
year of age, per 1000 live births, in a calendar year. This 
ratio is used, in dealing with infant mortality, rather than the 
death rate per 1000 infants living under one year of age, for 
the reason that in intercensal years the population under one 
year of age cannot be closely estimated. However, the infant 
mortality rate based on births is subject to error also, for 
the reason that if we do not have nearly complete birth 
registration the apparent rate will be higher than the actual; 
if the death registration is deficient, the apparent rate will 
be lower than the actual. If the percentage of death INFANT HYGIENE 
83 
registration remains nearly constant, while the percentage 
of birth registration materially increases, there may be an 
apparent lowering of the infant mortality rate, though not 
an actual reduction. In California, for example, in twelve 
years there has been an apparent reduction in the infant 
mortality rate of about 51 per cent. In the same period the 
birth rate increased (apparent, on account of more perfect 
birth registration) about 67 per cent., while the infant death 
D/a yratn /Vo. Z. 
//V//7/Z.T. /Z0BT//1/TY 
Ced/raJ /?//*«/«: -/CO 
//or/* /?//«n/fC - ec 
rt/ttate Vest - 7€ 
Wej/crh. '. \ * JO 
mTI [T^TT11 
CeaMs Orxfrr. C/?e Year .V/Zpe' 
/fCCC . E&/i/vata/ /f&v/a/'°r? Cnc(er \ 
Ohc Year p//??f Crr^^j 
rate per 1000 living under one year of age decreased only 
about 26 per cent. Approximately one-half of this reduction 
in infant mortality rates was apparent, and not actual. 
The infant mortality rate has been called the most sensi- 
tive index we have of social well-being, and to a.considerable 
extent of the effectiveness of public health administration. 
But in using it as an index of health administration effi- 84 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
ciency we must take certain factors into consideration, 
just as we must take such factors as age, sex and race 
composition of the population into consideration when we 
judge the healthfulness of a community from its general 
death rate. It is proper at this point to call attention to 
the marked variations in infant mortality rates in various 
sections of the United States, as shown by Crum in the 
April, 1919, issue of the American Journal of Public Health. 
These variations may be explained partly by climatic condi- 
tions and partly by other factors. (See Diagram No. II.) 
Some of the factors which affect the mortality rate are 
race, nationality, urbanization, industrialism and longevity 
of the -parents (heredity). The following figures are 
interesting as bearing on these various factors. 
Table XIII—Race and Infant Mortality, New York City 
Year 
White 
Colored 
1915 
96 
202 
1916 
91 
193 
1917 
87 
169 
1918 
90 
171 
1919 
80 
151 
1920 
81 
164 
1921 
69 
136 INFANT HYGIENE 
85 
Children’s Bureau 
H. F. Gray 
Nationality 
Water- 
bury, 
Conn., 
1914 
Johns- 
town, 
Pa., 
1911 
Man- 
chester, 
N. H., 
1913 
Vacaville, 
Calif., 
1910-1918 
All Nationalities 
121 
134 
175 
in 
Native Whites 
98 
104 
141 
Italian 
112 
183 
Lithuanian 
205 
Irish 
182 
Slovak 
177 
Serbo-Croats 
264 
French-Canadians 
207 
Polish 
174 
Greek 
White other than Latins 
133 
44 
Spanish and Italians 
263 
Chinese and Japanese 
98 
Table XIV—Nationality and Infant Mortality 
While the various racial and national groups directly 
compared live under the same general environmental condi- 
tions, environment cannot be entirely excluded as a factor 
in the death rate differences, as racial and national customs 
and food habits no doubt partly account for differences in 
the infant mortality. 
Brend1 gives the following figures bearing on the 
variation of infant mortality in Great Britain under urban 
and rural conditions: 
1 Health and the State, E. P. Dutton & Co., 1917. 86 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Average 
Range 
Rural Districts in England, 1914 
G2 
54 to 68 
Rural Districts in Scotland, 1914 
57 
46 to 69 
Rural Districts in Ireland, 1914 
50 
38 to 60 
Urban Districts in England, 1914 
138 
122 to 184 
Urban Districts in Scotland, 1914 .... 
124 
110 to 135 
Urban Districts in Ireland, 1914 
144 
143 to 145 
Table XV 
In France, for 1912, he gives the following figures: 
For towns of 5000 population and over Ill 
For rural districts 58 
In connection with these figures it should be noticed that 
some cities may have exceptionally low infant mortality 
rates, if there is no marked overcrowding or intensive 
industrial development, and if other conditions are favor- 
able. Such Pacific Coast cities as Seattle, Berkeley and 
Palo Alto are examples of large, medium and small sized 
cities with very low infant mortality rates. It should 
also be noted that New York City, in the face of very 
unfavorable environmental and racial conditions, has 
succeeded, by hard work and large expense under intelligent 
direction, in hammering down its infant mortality rate 
to a figure of which its health department may justly 
be proud. 
Heredity seems to play a large and important part in 
the determination of infant mortality. Longevity in the 
parents presupposes a low infant mortality, as the following 
figures show: INFANT HYGIENE 
87 
Table XVI—Percentages of Children Who Died in the First Five 
Years of Life, According to the Age of Death of Either Parent 
(Data of Beeton and Pearson) (3855 Children) 
Age of parent at death 
AH ages 
to 38 
39-53 
54-68 
69-83 
84 and 
over 
Per cent, for mothers 
Per cent, for fathers 
28 
26 
52 
49 
38 
34 
30 
27 
20 
22 
10 
17 
Table XVII—Percentages of Children Who Died in the First Five 
Years of Life, According to the Age at Death of the Father. 
(Royal Families—3200 Children Total Investigated) 
(Data of Ploetz)1 
Age of father at death 
All 16- 
ages 25 
26- 
35 
36- 
45 
46- 
55 
se- 
es 
66- 
75 
76- 
85 
86 and 
over 
Per cent, for fathers 
28 52 
32 
31 
31 
28 
26 
24 
3 
1 Popenoe and Johnson “Applied Eugenics” MacMillan Co. 
Three hundred and forty long-lived families (A. G. Bell): 
119 deaths under 5 years of age among 2259 children; a 
rate of 53 per 1000, for the first four years of life. 
The foregoing figures are strong evidence that heredity is 
an important factor in infant mortality. In the first group 
(data of Beeton and Pearson) the families were not speci- 
ally selected to eliminate any environmental factor, but in 
the second group (Royal families) the environmental 
conditions were apparently as good as money and knowl- 
edge could make them. And yet, with the environmental 
factor eliminated, the infant mortality rate is closely 
associated with longevity in the parents. We cannot 88 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
escape the conclusion that vitality and ability to live are to 
a considerable extent dependent on heredity. 
Poverty has been much discussed as a cause of a high 
infant mortality, but it is doubtful indeed whether poverty, 
per se, is an actual cause of such mortality. That it is 
frequently an accompaniment of high infant mortality is 
undoubtedly true, but a cause and effect relationship has 
not been proved, and is decidedly doubtful. Brend, for 
example, calls attention to the fact that the agricultural 
laborers in rural Wiltshire (England) are the poorest paid 
class of people in the nation, yet the infant mortality 
rate among them is very low (about 60 per 1000). Thou- 
sands of families of children have been raised under pioneer 
conditions, in extreme poverty, and yet the available 
evidence is that the mortality among them has been very 
low. The strong virile men and brave women who devel- 
oped the West were usually poor in material possessions, 
but their children were sturdy and fitted to survive prob- 
ably because of a fine heredity. CHAPTER XI 
CHILD HYGIENE 
After the first year of life, the principal causes of mortal- 
ity alter their relative importance. Table XVIII (P. 93) is 
derived from the 1917 Mortality Statistics for the U. S. 
Registration Area, to indicate these changes. 
In the second year of life, congenital debility and malfor- 
mations disappear, as a significant cause of death, and 
diarrhea and enteritis assume first place. Pneumonia 
takes second rank, followed by measles. Disorders of 
the nervous system, largely meningitis and convulsions, 
take eighth rank; meningitis and convulsions are, however, 
objectionable terms, unless carefully qualified by stating 
the primary cause of death, which would often lead to 
deaths from such reported causes being classified elsewhere. 
Tuberculosis, whooping cough and diphtheria, in the order 
named, are the important communicable diseases following 
pneumonia and measles. 
In the third year, pneumonia assumes first rank, with 
diarrhea and enteritis second. Diphtheria, in third place, 
becomes the most important contagious disease, and exter- 
nal causes, which include accidents, are fourth. 
In the fourth year, diphtheria assumes first rank of all 
causes of death, with pneumonia in second place. Whoop- 
ing cough drops to eleventh place, and scarlet fever appears 
in tenth place, which it never exceeds. In the fifth year, 
diphtheria still leads, with external causes second. Pneu- 
monia drops to third, and diarrhea and enteritis to fifth 
position, while tuberculosis rises to fourth place. 
89 90 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
In the ages 5 to 9 years, both inclusive, external causes 
of death take first place, followed by diphtheria, pneumonia 
and tuberculosis in the order named. Diseases of the 
circulatory system appear in eighth place and typhoid 
fever eleventh. 
In the ages 10 to 14 years, both inclusive, external causes 
are still first, but tuberculosis takes second place. Diseases 
of the circulatory system jump into third place. Probably 
this is due in part at least to tonsils and teeth neglected in 
childhood, and to the sequelae of contagious diseases. This 
rise in importance of diseases of the circulatory system 
indicates to a certain extent the need for more prompt and 
thorough correction of such physical defects as diseased 
tonsils and bad teeth. Pneumonia drops to sixth rank 
and diphtheria to ninth, but typhoid fever rises to eighth 
rank. 
This brief tabulation indicates that the factors of 
mortality in early years vary. The causes of death in 
early infancy drop down in the scale, while the communi- 
cable diseases, accidents and the results of neglect assume 
importance. These facts point to the need of com- 
municable disease control, the prevention of accidents, 
and the correction of physical defects, during the pre-school 
age, an age, however, of low total mortality. 
Perhaps because of this low mortality the pre-school 
age has been rather neglected by health officials. A well- 
organized health department often has infant hygiene 
nurses who look after the infants, and school nurses, physi- 
cians and dentists who look after the school children, 
but the pre-school child does not exist for them. He is, 
however, extremely important. This is the age at which 
many physical defects may be most easily prevented or 
remedied. Effective health supervision at this age will 
lighten the burden on the school medical inspection system. CHILD HYGIENE 
91 
Rank 
Under one 
1 
2 
3 
4 
5-9 
10-14 
1 
Early infancy 
Diarrhea and 
enteritis 
Pneumonia 
Diphtheria 
Diphtheria 
External 
External 
2 
Diarrhea and 
enteritis 
Pneumonia 
Diarrhea and 
enteritis 
Pneumonia 
External 
Diphtheria 
Tuberculosis 
3 
Pneumonia 
Measles 
Diphtheria 
External 
Pneumonia 
Pneumonia 
Circulatory 
4 
Other respiratory 
Tuberculosis 
External 
Diarrhea and 
enteritis 
Tuberculosis 
Tuberculosis 
Other digestive 
5 
Other general 
Pertussis 
Measles 
Tuberculosis 
Diarrhea and 
enteritis 
Other digestive 
Other general 
6 
Nervous 
Diphtheria 
Tuberculosis 
Measles 
Nervous 
Nervous 
Pneumonia 
7 
Pertussis 
External 
Nervous 
Nervous 
Other digestive 
Other general 
Nervous 
8 
Other digestive 
Nervous 
Pertussis 
Other digestive 
Measles 
Circulatory 
Typhoid 
9 
Tuberculosis 
Other respiratory 
Other digestive 
Other general 
Other general 
Measles 
Diphtheria 
10 
Measles 
Other general 
Other general 
Scarlet fever 
Scarlet fever 
Scarlet fever 
Genito-urinary 
11 
External 
Other digestive 
Other respiratory 
Pertussis 
Pertussis 
Typhoid 
Measles 
12 
Syphilis 
Dysentery 
Scarlet fever 
Other respiratory 
Circulatory 
Diarrhea and 
enteritis 
Scarlet fever 
Note.—The following abridged list of titles for tabulating causes of death has been used in preparing the data 
ofthisTable. (1) Typhoid fever. (2) Malaria. (3)Smallpox. (4) Measles. (5) Scarlet fever. (6) Whooping cough. 
(7) Diphtheria and croup. (8) Syphilis. (9) Other epidemic diseases. (10) Tuberculosis (all forms). (11) Dysentery. 
(12) Other general diseases. (13) Diseases of the nervous system. (14) Diseases of the circulatory system. (15) Pneu- 
monia and bronchopneumonia. (16) Other diseases of the respiratory system. (17) Diarrhea and enteritis. 
(18) Other diseases of the digestive system. (19) Diseases of the genito-urinary system. (20) The puerperal state. 
(21) Diseases peculiar to early infancy, and malformations. (22) External causes. (23) All other causes. 
Table XVIII—Rank of Important Causes of Death by Age Groups. U. S. Registration Area 1917 92 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
This is an additional argument for the general public 
health nurse. 
After the fifth year of life we enter what may be termed 
the school period and a number of new problems are 
presented. Among the most important are the control 
of communicable diseases arising in assemblages of children; 
the correction of physical defects which are retardants to 
educational progress and physical development; the prob- 
lems of sanitation and safety of school buildings and 
grounds, and the problem of teaching hygiene. 
Taking up first the problem of communicable diseases 
in schools, we find a number of moot questions. One of 
them frequently encountered is the matter of closing 
schools during epidemics. It is sometimes astonishing 
with what unanimity such closing is demanded, even by 
well-informed physicians. But valid evidence that schools 
are essential factors in the spread of communicable diseases 
is very meager. For different diseases the seasonal rise 
begins somewhat before, or rather later, than the opening 
of schools. The strongest argument against closing schools 
is that such practice does not materially reduce the amount 
of contact, which largely determines the progress of an 
epidemic. The children mingle just about as much outside 
of school as in school. The only exception is in the rural 
districts with scattered population where there is little 
intermingling of children aside from school. Closing such 
schools may be a useful procedure, as an aid to effective 
control measures required by regulation, but there is no 
evidence that in cities or towns closing has any effect in 
stopping an epidemic. 
On the other hand, if a few simple procedures are adopted 
while the schools are kept open, an effective control of an 
outbreak of disease may be had. With the children assem- 
bled in school it is far easier to observe and examine them, CHILD HYGIENE 
93 
suspected and incipient cases being detected at once and 
sent home for isolation. Absentees can be checked up 
and missed cases thus discovered.1 
1 Dr. M. J. Rosenau, Professor of Preventive Medicine and Hygiene in 
Harvard Medical School, “Preventive Medicine and Hygiene,” p. 1092: 
“The question of closing the schools when some one of these diseases 
breaks out is often a difficult one to decide. If the children commingle out of 
school, upon the streets and play-grounds, no useful purpose is accomplished 
by closing the schools. Closing schools is economically wasteful and usually 
has no influence on the course of an outbreak. Children are less apt to infect 
each other in the class-room than in the home or on the play-ground. As a 
rule better results will be obtained by daily inspection of all school children 
than by closing the schools.” 
Dr. F. C. Curtis, of Newton, Mass., in the American Journal of Public 
Health, vol. iv, p. 135, states: 
“Among the traditional methods of dealing with an outbreak of com- 
municable disease which have survived from the past, closing the schools 
when an epidemic appears seems to have lasted the longest. Indeed the 
public is so convinced that closing the schools is the necessary step to be 
taken in controlling an outbreak, that, if this is done, it rests assured that 
vigorous methods of control are in force and is satisfied. If, however, the 
health officer declines to close the schools he is blamed no matter how active 
he may be in checking the outbreak in other ways, and tremendous pressure 
is put upon him to compel him to close them. This pressure comes chiefly 
from the parents, but often, I am sorry to say, from the practicing physi- 
cians, and a man must have a very rigid backbone to withstand it.” 
J. Scott MacNutt, “Manual for Health Officers,” p. 259: 
“The matter may be summed up in saying that in sparsely populated 
country districts, where the children do not associate to any general extent 
except at school, closing may be effective; but that in towns and cities where 
there is certain to be a great deal of association in any case, it is of doubtful 
if of any value.” 
California State Board of Health, in a letter of instructions to local 
health officers issued October 19th, 1918: 
“In the opinion of the State Board of Health, schools should be kept 
open whenever the teachers can be relied upon to immediately exclude any 
child appearing with symptoms of any sort of illness. The well children 
in schools kept open in this manner will be much safer from contagion than if 
the schools were closed and they were free to associate on the streets. 
“The closing of the public schools is a measure that the State Board of 
Health does not favor, provided that the pupils are inspected daily by 
teacher or nurse, those who show signs of illness being immediately sent 
home.” 94 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Even if there be no system of medical inspection, the 
school teachers can cooperate with the health officer in 
making this plan effective. Every teacher can observe 
her children for departure from normal health, and imme- 
diately notify the health officer if any suspicious symp- 
toms are noticed. Suspected children can either be held 
in isolation at the school until the arrival of the health officer, 
or sent home pending investigation by him, whichever is 
most practicable and convenient. If this is done the first 
thing every morning, before classes are convened if possible, 
experience has shown that there is little if any danger to 
the other children. 
Teachers can be instructed as to what special symptoms 
to watch for, and this will increase the efficiency of their 
work. If there be a school nurse or medical inspector, 
much of the work of detecting incipient cases will fall on 
them, but the teacher should always be considered the 
outpost of the line of defense. 
No matter how good a school medical inspection system 
is, most of the control measures must be taken by the health 
officer. There are five cardinal rules which should guide 
him in such work. 
1. Keep the well children in school under close observa- 
tion. 
2. Look up all absentees, and run down all rumors, to 
locate and control all missed and atypical cases, and cases 
in the prodromal stages. 
3. Isolate all cases, whether frank, atypical or prodromal. 
Tentative isolations, where disease is suspected, are very 
useful. 
4. Quarantine susceptible contacts for a period equal 
to the maximum incubation period of the disease. 
5. Carefully examine all persons isolated or quarantined, 
before they are released, and require rigidly that all chil- CHILD HYGIENE 
95 
dren returning to school after absence obtain a written 
permit from the health officer. 
It is remarkable the promptness with which epidemics 
of diphtheria, scarlet fever and whooping cough can be 
controlled by the effective use of these measures. There 
are indications that they will prove fairly effective with 
measles, although here a great amount of work is necessary 
for any successful control, and it is at best precarious. 
Every possible effort should be made to obtain the coopera- 
tion of the school teachers in this work. We have found 
that they will cooperate well if tactfully shown how valuable 
and important their assistance is, and are given definite, 
concise information as to their obligations. In chickenpox 
and mumps control is ineffective, as there is no sure means 
of early diagnosis. With smallpox, universal vaccination 
is the only effective control measure, and the only one 
worth trying. 
Mention has already been made of the health importance 
of certain physical defects (tonsils and teeth) as possible 
factors in children’s death from diseases of the circulatory 
system. In addition, physical defects act as deterrents to 
educational progress, and therefore the educational authori- 
ties have taken a great and proper interest in their 
correction. 
Because these two interests bear upon the same problem, 
there has arisen some difference of opinion as to whether 
school medical inspection should be performed by the 
health department or the school department. Each depart- 
ment can present arguments why medical inspection should 
be under its supervision. Primarily a large part of the work 
(communicable disease control) is solely the function of the 
health department, as the legal authority to do this work 
is lodged by law exclusively in the health authorities. There 
is nothing to be gained by arguing as to who shall do and 96 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
pay for the work, provided it be done effectively, and the 
health and school authorities cooperate thoroughly and 
cordially. One might as well quarrel as to whether his 
right hand shall spend money from his left hand pocket, 
or vice versa. 
Defective teeth are the most frequently encountered 
physical defects. It is really appalling the tremendous 
amount of dental defect existing. In schools of isolated 
rural districts it is not unusual to find all the children 
afflicted with dental caries. Very often the first permanent 
molars are decayed beyond hope of saving. Such conditions 
not only lead directly to a reduction of physical efficiency, 
but lay the foundation for systemic disorders which may 
result in premature death in early adult life. 
The teaching of dental hygiene in schools, tooth brush 
drills, and dental clinics (travelling clinics for rural schools) 
are the principal corrective measures adopted. Defects 
discovered on examination are either referred to the family 
dentist, or corrected in the clinics. 
Diseased or hypertrophied tonsils, and adenoids, are 
next most frequently encountered. Routine medical in- 
spections are needed to detect these defects, which are then 
referred to the family physician, or to a public clinic. 
Some large cities maintain special operative tonsil and 
adenoid clinics for school children. Travelling clinics can 
be used effectively in rural districts. 
Eye and ear defects follow in frequency. The existence 
of such defects may be easily determined by simple tests, 
but in the case of eye defects elaborate examination to 
determine the proper glasses is required. This may be 
supplied by a special optical clinic, or the family referred to 
an occulist. In some places an arrangement can be made 
with the occulists to examine such children as are found on 
preliminary test to have eye defects. CHILD HYGIENE 
97 
Teeth, tonsils, adenoids, and eye and ear defects are 
those most commonly encountered. Eye and ear defects 
are impediments to school progress, as they directly impair 
the perceptive faculties. Tonsils and adenoids, aside from 
the danger of systemic infection, act to retard the mental 
processes. These defects, therefore, constitute a bar to 
normal school progress, and are of especial importance to 
the educational authorities. There are a large number of 
other miscellaneous defects which it is unnecessary to 
discuss here. Attention should be called, however, to the 
growing use of school lunches to combat malnutrition. 
Simply to discover a defect and call the parent’s attention 
to it will accomplish little. Experience shows that such a 
program gets only a small percentage of defects corrected. 
The examinations must be followed up tactfully but 
persistently in order to obtain corrections. In this work 
the school nurse is of especial value as a complement to 
the wmrk of the medical and dental inspectors. To get 
results from the follow-up work there must be organized 
some means of having the defects corrected, either by clinics, 
or by cooperation of the physicians and dentists. 
There is little use in attempting to teach hygiene and 
sanitation in the schools if the children while at school are 
surrounded by grossly insanitary conditions. “Example 
is better than precept.” For the educational effect alone 
the school should have the most sanitary buildings and 
grounds in the community. This is of importance entirely 
aside from any need of health protection. There is an old 
story about a traveller driving with a native through a 
rural district. As they passed a dilapidated, ramshackle 
old building the traveller asked “What place is this?” 
“Oh!” said the native, “that is only our school. If 
you want to see a fine, modern, sanitary building, come look 
at our jail.” Common humanity demands that even law 98 
ELEMENTS OF PUBLIC HEALTH ADMINISTKATION 
breakers shall be decently treated while in confinement, but 
it is absurd to build fine jails and other public buildings, 
and place our children in mean quarters for their schooling. 
Most of the sanitary problems which arise in schools are 
discussed elsewhere, and it is unnecessary to repeat them 
here at length. Safe, wholesome drinking water, and 
plenty of it, is one fundamental requirement. The water 
should be obtainable in a sanitary manner. Excellent 
drinking fountains, which avoid largely the defects of 
earlier designs, are now available. They may be had at 
moderate cost, even for schools which do not have a 
pressure water system. Sufficient lavatory facilities, with 
soap, individual towels, and running water, if possible, 
should be provided, and the important detail of washing 
the hands after visiting the toilet should be insisted 
upon. Sanitary excreta disposal is also fundamental. The 
old-fashioned open school privy is a moral and hygienic 
abomination, and must be replaced either by modern 
plumbing or by sanitary fly-proof privies. Schools should 
set a model for sanitary privies, if used, which the whole 
community can have as a practical demonstration. CHAPTER XII 
WATER SUPPLY 
There is an old saying that “ You can’t tell from looking at 
a frog how far he can jump.” It is also impossible to tell 
from looking at water whether it is safe to drink. Many a 
clear, sparkling mountain water, which has been considered 
locally to be absolutely safe and above suspicion, has 
become polluted with typhoid or dysentery bacilli. 
And, on the other hand, there are waters which are certainly 
unpleasant to look at, but which are not contaminated 
with disease germs. There are many misunderstandings 
in the public mind regarding the essential factors in a safe 
and satisfactory water supply. Too often these essentials 
are not considered, and relatively less important matters 
cause great concern. For example, suppose a case of 
typhoid fever occurs in a family which gets its water from a 
well. The first possible source of infection suspected is the 
well. If there is a pig-pen or a horse-barn within a hundred 
feet of the well, the public is at once convinced that the 
well water is infected. The fact is overlooked that some 
human case or carrier of typhoid fever must have contami- 
nated the well water before it could have been the cause of 
a case of typhoid fever. Other possible causes, such as 
contact, or fly-borne infection, or milk, are often over- 
looked. The health officer must take all these possible 
vectors of infection into account in making an epidemi- 
ological investigation of diseases such as typhoid fever or 
dysentery which may be water-borne. 
There are certain general characteristics of water-borne 
epidemics which the health officer should keep carefully 
99 100 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
in mind. Such epidemics are as a rule insidious and slow 
in onset, and gradual in decline, but there are many 
variations. For example, a single brief infection of a water 
supply may cause a brief rise followed by a number of 
irregular, straggling cases for a short period. If the 
infection is continuous but small in amount, the cases will 
occur intermittently. A massive continued infection will 
result in a continuous high case-rate. 
Cases are not confined entirely to those who use the 
water, as there may be a number of secondary contact 
infections, but a very large proportion of the cases will be 
among users of the infected supply. 
Quite frequently a water-borne outbreak of typhoid fever 
or dysentery is preceded by an outbreak of intestinal 
disorders. 
If an outbreak is due to polluted public water supply, 
the cases are generally widely scattered in the community, 
and not confined to a particular section, but are mostly 
found among regular or intermittent users of the water 
affected. 
If the preliminary epidemiological investigation points 
most strongly to a polluted water supply, the next step 
is to secure reasonable proof of the assumption. This is 
done in two ways: 
1. A sanitary survey of the watershed of the supply must 
be made to locate the point at which the contamination may 
be received (e. g., sewer, privies, etc.). 
2. Bacterial examinations must be made of the water to 
indicate the amount of contamination. It is very seldom 
possible to isolate B. typhosus from a water supply, so we 
resort to the indirect method of determining the presence 
of B. coli, a normal inhabitant of the human intestine. 
Chemical analyses were formerly much in vogue, but the 
B. coli determination, if properly interpreted, is of much Water supply 
101 
more value. It must be remembered that B. coli is also 
found in animal intestines, and therefore the sanitary survey 
may show both the possibility, or the fact, of animal 
contamination of the supply, as well as human contamination. 
If the epidemiological study, sanitary survey and bacteri- 
ological examination combined show that the water supply is 
the source of infection, three things should be done at once. 
1. Notify the public to boil the water (Note: if suspicion 
attaches to the water, this should be done at first, pending 
the result of the various investigations). 
2. Disinfect the water supply by emergency chlorination 
with liquid chlorine, or with chloride of lime. This may 
also be done at the first suspicion of the water, pending the 
outcome of the investigation.1 
3. If possible, remove the source of infection of the water 
supply (privy contents, sewer, etc.), so as to prevent con- 
tinued contamination of the wAter. 
After these emergency steps have been taken, it is highly 
advisable that plans be made and carried to completion, 
at as early a date as possible, to render the water supply 
permanently safe. Any of the following measures may be 
adopted singly or in combination: 
1. Obtain a new supply of unquestioned safety. 
2. Provide adequate long-period storage in large 
reservoirs. 
3. Provide filtration. 
4. Provide chlorination. 
The health officer should not attempt to prescribe the 
type of permanent treatment, but should use his influence 
to see that such matters are placed in the hands of an 
engineer well-qualified by training and experience to 
handle the matter. 
1For emergency disinfection, about three parts of chlorine per million 
parts of water is advisable until laboratory controls are established. 102 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Water supplies are in general of two main types, surface 
and ground-water supplies. Surface supplies, as a rule, 
are more subject to dangerous contamination than ground 
water supplies, and are more apt to be turbid, or muddy, 
especially in flood flows. Ground-water supplies are more 
apt to be hard or highly alkaline, and so more or less unsuit- 
able for manufacturing purposes. The choice of a supply 
depends largely upon availability and safety; secondly, upon 
the cost of construction and maintenance of works. 
Waters which, while readily available, are unsatisfactory 
either in safety or hardenss, may be treated to render them 
safe and satisfactory for consumption. Hard waters may 
be chemically treated by either the zeolite or lime-and-soda 
process, to give a soft clear water. This is essential for 
many industrial processes. 
There are several methods of treating water to render it 
safe, or to improve its appearance. Three main conditions 
are encountered: 
1. Bacterial contamination. 
2. Turbidity. 
3. Color, tastes and odors. 
The various types of treatment designed, either singly or 
in combination, to correct these factors are: 
1. Storage and sedimentation, 
(a) Without coagulation. 
(ib) With coagulation. 
2. Filtration. 
(a) Slow sand. 
(b) Rapid sand. 
3. Disinfection. 
(a) With hypochlorites. 
(6) With liquid chlorine. 
(c) Minor processes. 
4. Miscellaneous processes. 
(o) Algicides. 
(b) Aeration. WATER SUPPLY 
103 
The application of these types of treatment will be briefly 
discussed. 
1. Prolonged storage in impounding reservoirs is advan- 
tageous in removing a large part of turbidity, and in 
reducing the numbers and virulence of pathogenic bacteria. 
It may result in unpleasant tastes and odors due to vari- 
ous non-pathogenic micro-organisms, especially algae and 
diatoms. Impounding reservoirs are primarily built to 
give a continued supply in low-water periods, and the 
removal of turbidity and bacteria by sedimentation is a 
secondary factor. 
Sedimentation in special basins is frequently used prior 
to slow sand filtration, and always, with chemical coagu- 
lation, prior to rapid sand filtration. The principal 
chemicals used for coagulation are sulphate of alumina 
(alum), and sulphate of iron with lime. Sulphate of 
alumina combines with the natural alkalinity of the water 
to produce a flocculent precipitate, which, in settling out, 
carries most of the turbidity and a large portion of the 
bacteria with it. The sulphate of iron combines with the 
lime to effect the same result. Highly colored waters 
are improved in appearance by coagulation. 
2. There are two principal types of filtration through 
sand, slow sand filtration, and rapid (sometimes miscalled 
“mechanical”) filtration. Both are capable of removing 
upwards of 96 per cent, of all bacteria and other micro- 
organisms in the water. Slow sand filtration, which is 
seldom preceded by coagulation, though sometimes 
preceded by sedimentation, or by preliminary “roughing” 
filters, is best adapted to waters which are not turbid. 
Slow sand filters are not adapted to treating highly turbid 
waters,1 or waters in which the sediment is very finely 
divided. The amount of ground area available for the 
plant is also a factor to be considered. Such filters operate 104 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
at an average rate of about 3,000,000 gallons per acre per 
day, seldom higher than 5,000,000 gallons per acre per day. 
Slow sand filters, when the surface becomes clogged, are 
cleaned by scraping off the dirty top layer of sand. 
Rapid sand filters are always preceded by coagulation and 
sedimentation. The filters are operated at a rate of 
between 100,000,000 and 150,000,000 gallons per acre 
per day. When the sand becomes clogged, the filters are 
cleaned by reversing the flow of water, and carrying the 
mud and coagulant floe over a gutter a few feet above the 
sand layer. This is spoken of as “washing” the filter. 
Rapid sand filters are especially efficient in treating highly 
turbid or colored waters, and may be adopted also where 
only a small space is available for the plant. Their bacterial 
efficiency is high, usually well over 95 per cent, removal. 
3. Disinfection is primarily utilized to make a polluted 
water supply safe by destroying the dangerous bacteria, 
such as B. typhosus or B. dysenteriae. The two principal 
types in use are “hypochlorite” disinfection, in which 
calcium hypochlorite (chloride of lime), or sodium hypoch- 
lorite, are used as disinfecting agents; and the liquid 
chlorine process. The latter, because of the simplicity of 
handling, the lower labor cost, and the highly efficient 
dosing apparatus which is now available, is the method of 
choice. Chlorine gas, when added in the proportion 
of two parts per million of a moderately polluted water, 
will effect complete sterilization without causing a notice- 
able taste. Usually a much smaller dosage will suffice for 
the average water. 
There are several minor types of sterilization, such as 
ozone treatment and the ultra-violet ray. The ozone 
treatment is not reliable, and the ultra-violet ray, while 
promising in certain spheres, is not sufficiently developed 
to be generally adopted. WATER SUPPLY 
105 
4. Among the minor purification processes which may be 
briefly mentioned are the copper sulphate treatment and 
aeration. Copper sulphate is especially useful in prevent- 
ing the growth of algae, diatoms and other micro-organisms 
which cause offensive tastes and odors, especially in 
impounding reservoirs. It is usually used in the proportion 
of about one part per three to five million parts of water. 
Aeration, effected by causing the water to splash violently 
over special towers in the presence of air, is useful in certain 
cases in reducing offensive odors. 
Each of the processes briefly described has a certain 
field of usefulness, and is adapted to meet certain conditions. 
A process should not be used in a situation to which it is 
not applicable. Competent engineering advice should 
be sought in all cases involving water purification. 
Laboratory examinations of water are valuable aids in 
the sanitary control of supplies. Three types 
are available: 
(a) Bacteriological 
(b) Microscopical 
(c) Chemical 
Bacteriologic determinations are of value in indicating the 
safety of supply. Two counts are used, the gelatin plate 
at 20 degrees C., and the agar plate at 37 degrees C. The 
former indicates the total number of bacteria (principally 
normal water bacteria) which will develop at ordinary 
temperatures; the latter indicates the number of bacteria 
which develop at blood heat (principally derived from 
animal or human contamination). Tests are made for B. 
coli at various dilutions. The isolation of B. typhosus or 
dysenteriae is difficult and is seldom attempted. 
Microscopical determinations are made for minute 
animal or vegetable organisms, some of which may cause 
objectionable tastes and odors. 106 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Chemical analyses are usually made to determine alka- 
linity, hardness and other chemical characteristics. Form- 
erly much used in connection with nitrogen and chlorine 
tests, to determine the sanitary quality of the water, the 
chemical tests have been generally abandoned in favor of 
bacterial determinations, so far as the sanitary signifi- 
cance is concerned. 
Both bacterial and chemical determinations are essential 
in the control of rapid sand filtration, and chlorination. 
A warning should be given in regard to the interpreta- 
tion of analyses of water. Interpretation of the results of 
laboratory examinations without supporting data given by 
a sanitary survey of the supply is a rather unsafe procedure 
and may lead to grave error. All possible information 
should be collected as to a water supply, and judgment be 
based on all the available data, rather than on analyses 
alone. A series of samples is much better as a basis of 
judgment than a single sample, and no judgment, except 
a tentative opinion, should ever be passed upon a single 
sample. Water supplies are often unjustly condemned 
as a result of conclusion drawn from a too superficial exami- 
nation into the question of the presence or absence of 
actually dangerous contamination. CHAPTER XIII 
SEWAGE DISPOSAL 
To some people, the subject of sewage disposal is a very 
simple matter: just run the stuff through a “septic tank,” 
and, they will tell you, it will come out pure and sparkling. 
At the other extreme are the people who consider it an 
exceedingly mysterious process, but they have a patent 
method which is far superior to anything else. As a result 
of the first and second false doctrines, coupled perhaps 
with much technical jargon, the public often becomes 
hopelessly befuddled, and in the end the city fathers may 
have foisted upon them a sewage disposal plant not well 
adapted to their needs, and about the operation of which 
they have but the vaguest ideas. 
Of course, the large cities are able to retain high-grade, 
technically trained and experienced engineers to design 
and construct their sewage disposal works. Usually, 
therefore, they get the type of treatment best suited to 
their requirements. But the small town is seldom able 
to engage especially expert engineering talent, and often 
suffers as a result. 
There is really nothing mysterious about sewage disposal, 
neither is it absurdly simple. The general principles are 
easily understood by anyone of average intelligence, but 
the working out of the details is an important factor 
in each installation. It is here that it pays a community 
to purchase the very best engineering brains it can afford. 
Every community has a sewage disposal problem. Many 
towns under, say, 500 population may not believe it, 
107 108 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
because they have no sewer system. But human excrement 
accumulates in their midst, in privies and cesspools, 
and even if there be no water-carriage sewer system, there 
is still the problem of excreta disposal. Simply getting the 
stuff out of sight, in privies and cesspools, does not solve 
the problem. If extensively used, cesspools eventually 
seriously contaminate the ground water. In time, too, 
most of the ground available is used up, and conditions 
become more or less intolerable. Privies, on the other 
hand, while they may place the excrement out of sight, 
seldom get it out of mind. 
Not only is the common type of privy a stench in the 
nostrils of humanity, but it is a most potent danger. The 
ubiquitous fly provides a return circuit of the dejecta to 
the alimentary canal of man, for the fly impartially 
sojourns in the privy or frolics upon our food. Unquestion- 
ably the fly and the privy are responsible for a large amount 
of typhoid, dysentery and intestinal disorders in unsewered 
communities. It is perfectly possible, however, to make 
the privy reasonably sanitary and decent, and to keep it 
so. To accomplish this, the public attitude must be 
changed. From considering it as a necessary evil (and 
very evil indeed, at that), the privy must be looked 
upon as essential, and as necessary to be kept clean, as 
the kitchen. 
The first sanitary requirement is that the privy must he 
fly-proof, the second that it be neat and clean. It must 
also be private, but accessible. The first is obtained by 
proper construction, using sound, first-quality lumber, 
careful workmanship and screens; the second, by care in 
maintenance. Designs of sanitary privies may usually be 
obtained from the State Department of Health on request, 
Pit privies (in which the excreta are deposited in deep 
pits dug below the privy) are suitable for use in ground SEWAGE DISPOSAL 
109 
which is fairly uniform, and not seamed or fissured. Where 
the underlying rock or soil is fissured, as, for example, 
in limestone formations, pit privies will probably cause a 
marked pollution of the underground water. If this be 
used for domestic water supply, a great danger will be 
created. In such cases, if privies must be used, the pail 
system (in which the excreta are retained in pails or con- 
tainers which may be removed and the contents disposed of 
elsewhere) is more satisfactory. The objection to the pail 
system, however, is that a collection and disposal system 
must be provided to take care of the can contents. In 
unsewered towns this becomes a big problem. It can be 
solved, as experience has shown, but the great danger, and 
the usual experience, is that eventually the collection and 
disposal system either breaks down entirely or becomes 
inefficient, with a resulting intolerable nuisance. 
In the end, and usually very shortly after the installation 
of a public water supply, the community realizes the 
necessity of adequate sewerage on the so-called water- 
carriage plan. With such an installation, the problem 
of sewage disposal is transferred from the midst of the 
community to a point more or less distant from the town. 
The conditions are now reversed. Instead of the disposal 
of a moderate amount of semi-solid material, scattered 
through the community, we have the problem of disposal 
of a comparatively large amount of water, in which the 
solid wastes are suspended, and this liquid waste is usually 
concentrated at one point outside the town. 
The two most primitive methods of disposal of such 
sewage are: 
1. Discharge into a stream, lake or ocean. 
2. Discharge upon land. 
If the river flow is large, as compared with the volume of 
sewage, there may be no nuisance created. But there is 110 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
serious objection to the discharge of raw sewage into a 
river, as this may dangerously contaminate the supply 
of towns which take their water from the stream below. 
If the stream flow is small, as compared with the sewage 
flow, there may be great nuisance due to the foulness of 
the stream. If the sewage is discharged into lakes or 
bays, there will be, probably, a nuisance due to the forma- 
tion of banks of sewage sludge. 
If the sewage is discharged upon land, there will prob- 
ably be a nuisance due to deposits of sewage solids upon the 
surface. This may be obviated to a considerable extent by 
careful choice of the kind of soil; by rotation of dosing on 
separate plots, and by cultivation. But seldom is such 
adequate attention given. 
In order to avoid these difficulties, various processes of 
sewage treatment have been developed, with a view to 
lessening or obviating the danger or nuisance in sewage 
disposal. In general four types of processes have become 
more or less well-established. 
1. Processes in which digestion, or liquefaction, of the 
sewage solids is carried out under anaerobic conditions. 
The primary purpose here is to reduce the amount of sewage 
solids to be disposed of. 
2. Processes which endeavor to render the sewage stable 
in character, and incapable of further decomposition. 
3. Processes for the sterilization of sewage. 
4. Miscellaneous processes of various kinds, some for the 
recovery of fats, fertilizers or other by-products, etc. 
The early experimenters in sewage disposal noticed that 
when sewage was left in a quiescent condition for a period 
of time, a state of putrefaction set in, with the digestion or 
liquefaction of a certain amount of the solids, and the 
formation of various gasses, such as hydrogen sulphide and 
methane. This state occurred after the dissolved oxygen SEWAGE DISPOSAL 
111 
in the sewage liquid was exhausted. Because this lique- 
faction is accomplished by the action, on the organic 
sewage solids, of certain types of bacteria which develop 
only in the absence of free oxygen, these processes are 
generally spoken of as anaerobic, or “septic.” processes 
of sewage disposal. This type of process is a combination 
of sedimentation of sewage solids, and the reduction of 
volume of the settled solids by biologic action. 
The two principal types of works for treatment of sewage 
by anaerobic action are the “septic tank,” and the “Imhoff 
tank.” Although there are variations in details, funda- 
mentally a septic tank is a chamber or tank in which the 
velocity of flow of sewage is retarded to a point at which a 
large portion of the suspended solids will settle out of the 
flowing sewage, and, being deposited in the bottom of the 
tank, will undergo anaerobic decomposition and partial 
solution. This reduces the amount of sludge to be eventu- 
ally disposed of, but does not alter the fact that this sludge 
must somehow or other be gotten rid of. In fact the 
disposal of sludge is the most difficult problem in sewage 
disposal. Usually sludge is placed upon porous land or 
gravel beds to drain and dry, and then worked into the 
ground. 
The liquid sewage which flows from a septic tank (the 
“effluent”) is by no means purified. It is often much 
more foul and offensive than fresh sewage, and may contain 
many more bacteria. But because a considerable part of 
the suspended solids are removed, the effluent can be dis- 
posed of on land or by dilution in streams or lakes with 
less nuisance than a crude sewage. Over-foulness of the 
effluent can often be corrected by reducing the time of 
detention in the tank. A common fault of inexperienced 
engineers is to design the tank too large, which results in 
over-septicization of the effluent. 112 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
In order to avoid this over-septicization, by separating 
the functions of sedimentation and sludge digestion, the 
Imhoff tank was developed. In this type of tank there 
are two parts: an upper sedimentation chamber, in which 
the velocity of flow is reduced to a point at which the solids 
are largely deposited, and a lowTer chamber, into which the 
solids settle, through a slot between two slanting bottoms 
of the upper chamber. In this lower chamber the solids are 
partially digested and liquefied by anaerobic action. The 
comparatively fresh sewage which flows from the upper 
chamber is not fouled by the decomposition products of 
the sludge below, and so is less offensive and generally 
more easily disposed of than is a septic tank effluent. 
Sedimentation tanks, with separate tanks into which the 
sludge and scum are discharged and there digested, are 
also being used to a limited extent. 
Septic and Imhoff tanks are the principal types of 
preliminary treatment processes in use today. As stated 
previously, their primary object is to reduce the amount 
of sludge to be handled. One other preliminary process 
may be mentioned briefly. Where very large volumes of 
water are available in which to dispose of sewage by dilution, 
the mechanical removal of solids by screens is sometimes 
sufficient. Various types of screens have been evolved. 
The principal difficulty in their operation is the matter 
of disposal of the solids, which are highly offensive and 
potentially more dangerous than tank sludge. 
The second general type of process is that in which the 
aim is to render the sewage comparatively stable and not 
subject to further decomposition. This is accomplished 
by methods directly the reverse of septic action, namely, 
by oxidation of the unstable organic substances dissolved 
or suspended in the sewage. Often these processes are 
preceded by sedimentation tanks of various types (includ- SEWAGE DISPOSAL 
113 
ing septic and Imhoff) to remove a large part of the sus- 
pended solids. Three principal types of plant are in most 
general use. These are contact beds, sprinkling filters 
and intermittent sand filters. The activated sludge 
method, being an aerobic process, may also be included here. 
Contact beds are tanks, filled with coarse broken stone or 
gravel, which are alternately filled with, and emptied of, 
sewage. After each emptying the bed is allowed to stand 
idle for several hours, to accumulate a fresh supply of 
oxygen from the air. The surfaces of the stones or gravel 
become coated with a zoogleal jelly, consisting largely 
of aerobic bacteria and microscopic organisms, and various 
worms and other lower animals. During the filling period, 
these organisms act upon the organic materials dissolved or 
suspended in the sewage, and oxidize them, to a consider- 
able extent, to more stable forms of inorganic nitrogen 
compounds. Contact beds eventually, after long periods, 
become more or less clogged, due to deposition of solids 
and accumulation of zoogleal masses, and the filling 
material then has to be removed and cleaned. 
A sprinkling filter consists of a bed of coarse stone, four 
or more feet deep, with open sides (usually) and large open 
underdrains, upon the surface of which the sewage (after 
screening or sedimentation) is sprinkled. In trickling 
over the surfaces of the stones in the filter, the sewage 
comes in contact with zoogleal films and various worms, 
and to a considerable extent the dissolved and suspended 
solids are oxidized to stable compounds. Usually a sprink- 
ling filter is followed by a sedimentation tank, as it dis- 
charges considerable suspended solids, and at certain 
times may “unload” a large amount of them. 
Intermittent sand filters are beds of sand, well under- 
drained, to which the sewage, usually after sedimentation, 
is applied at intervals. There is a marked straining action 114 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
iii removing suspended solids, as well as an oxidization of 
dissolved organic material. The beds are allowed to 
rest for a period between dosings, to accumulate a fresh 
supply of oxygen. 
In the activated sludge process, air is constantly blown 
through the sewage, in order to accomplish oxidization of 
the organic matter by aeration. Sludge from previous 
treatment, which is “activated,” or well-seeded with aero- 
bic bacteria, is constantly added to the inflowing sewage, 
in definite proportions determined by experiment. From 
time to time, as required, sludge is withdrawn and run onto 
drying beds. When fairly dry, it may be disposed of as 
fertilizer. 
There is practically only one process available for 
sterilization, the third type of treatment process mentioned. 
This is by chlorination. The Miles acid process, however, 
can effect a practical sterilization of sewage. Either 
liquid chlorine, or calcium hypochlorite, may be success- 
fully used for sterilization. The process has been discussed 
in the chapter on “Water Supply,” and it is only necessary 
to state here that considerably larger amounts of available 
chlorine are required for treatment of sewage, as compared 
with water. From 3 to 15 parts per million of available 
chlorine are necessary to effect reasonable disinfection of 
sewage, the amount depending partly upon the character 
of the raw sewage, partly upon the character of other treat- 
ment (tanks, filters, etc.), and partly upon the degree of 
disinfection necessary. 
In the fourth type of miscellaneous processes may be 
briefly mentioned the Miles acid process. In this form of 
treatment, sewage is acidulated, either by sulphuric acid, 
niter cake, or by blowing sulphur dioxide gas into it, which 
effects a more or less complete sterilization, and breaks 
down soaps to fats, making the recovery of grease practi- SEWAGE DISPOSAL 
115 
cable. Electrolytic treatment may also be mentioned, 
but this has never proved practical. 
The foregoing presents a very brief survey of sewage 
disposal processes. A few words may be said in respect 
of their relative adaptability and efficiency. Where the 
amount of dilution (ratio of diluting water to the sewage 
flow) is great, and there is no contamination of a drinking 
water supply to be considered, simple screening, to avoid 
nuisance which might occur from the deposition of banks 
of sewage solids, may be sufficient. Screening, however, 
presents a problem in disposal of the solids, which are 
extremely offensive. Well-operated fine screens may be 
expected to remove from 10 per cent, to 30 per cent, of the 
total suspended solids in sewage. Screening is often a 
useful preliminary treatment, prior to subsequent disposal 
methods. 
If screening is insufficient, sedimentation, either in 
Imhoff or septic tanks, may suffice. These tanks may be 
expected to remove from 30 per cent, to 70 percent, of the 
total suspended solids. The sludge, particularly from the 
Imhoff tanks, is more easily disposed of than screenings, 
and is less offensive. Also, the volume of solids to be 
handled is reduced by these processes from 10 percent, to 
40 per cent. The effluent from either type of tank, how- 
ever, is not suitable for discharge into a stream used as a 
public water supply, unless there is further and more 
adequate treatment. 
Imhoff tank treatment is perhaps the most suitable 
preliminary process in connection with final treatments 
such as sprinkling filters or intermittent sand filtration. 
It is also well adapted as a preliminary to disposal by 
irrigation on land. 
Of the oxidization, or stabilizing, processes (contact 
beds, sprinkling filters, intermittent sand filtration, and 116 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
activated sludge process), the sprinkling filter is perhaps 
the most widely used, and is capable of producing a fairly 
stable effluent. In general a reduction of from 85 per cent, 
to 90 per cent, of total solids, and a reduction of 90 per cent, 
to 95 per cent, of bacteria, may be obtained with proper 
design and careful operation. Sprinkling filters are especi- 
ally adaptable where the area for a disposal plant is limi- 
ted. With sufficient dilution ratio, sprinkling filter effluents 
may be discharged into streams without placing any marked 
burden on water purification works for supplies taken 
from the stream below the point of discharge. 
Contact beds may be used in place of sprinkling filters, 
where the available fall through the treatment works is 
less than required for sprinkling filters. A reduction of 
total suspended solids, of from 80 per cent, to 90 per cent, 
and a reduction of bacteria of about 80 per cent., may be 
obtained. Contact beds have not been as frequently 
adopted as sprinkling filters, in this country. 
Intermittent sand filters in general give the most satis- 
factory effluent, if intelligently operated. A reduction of 
95 per cent, in total suspended solids, and of 98 per cent, 
in bacteria, can be obtained. The effluent may be, as a 
rule, safely discharged into any stream. 
On account of the high initial cost and expense of opera- 
tion, the activated sludge process apparently is unsuitable 
for use, except in very large cities, with conditions especially 
favorable to it. Many of the details of this process remain 
to be worked out. 
Sterilization by chlorination may be required where a 
large volume of sewage must be discharged into a stream 
from which a water supply is taken. As a rule, treatment 
in Imhoff tanks and sprinkling filters, prior to chlorination, 
will effect an economy in cost, by reducing the amount 
of chlorine required to disinfect such an effluent. CHAPTER XIV 
WASTES DISPOSAL, SANITATION AND HOUSING 
“Oh, Sanitation, what crimes are committed in thy 
name!” So we might paraphrase a famous saying in 
respect of liberty. Some of the ancient and discarded 
notions as to the relation of sanitation to disease transmis- 
sion could now be dismissed with a smile, were it not for the 
fact that these ideas are still firmly planted in the minds of 
many of the elder generation, and also because careless 
thinkers have demanded clean-up campaigns to ward off 
or check epidemics of diseases which have no known or 
probable relation to insanitary conditions. Who among 
us has not heard some well-meaning elder describe the 
danger of contracting diphtheria from defective plumb- 
ing, or typhoid from “sewer gas,” or say that a pile 
of garbage is dangerous as a source of typhoid, or bad 
water a source of malaria. And even recently we have 
seen misguided persons utilize the public fear of infantile 
paralysis (polio myelitis) as an excuse for putting over 
a clean-up campaign! 
Good sanitation is emphatically desirable in itself, and 
does not need to be misrepresented to bring it about. We 
must, however, keep in mind the difference between the 
aesthetic and the health aspects of sanitation. Take the 
hog-pen as an example. A hog-pen may be a nuisance, and 
highly objectionable on aesthetic grounds, but its rela- 
tionship to health is rather doubtful; we do not contract 
any human diseases from hogs, except that eating the flesh 
of hogs may cause cases of trichinosis and tapeworm. 
117 118 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Of course, a filthy hog-pen may breed flies, and these flies 
may carry typhoid or dysentery if there are adjacent open 
privies where the flies may obtain infection. But most flies 
are bred in stable manures. On the other hand, an open 
privy is a potential or actual menace to health, as well 
as an offense against aesthetics. A marshy area which 
breeds Anopheles mosquitoes may not be offensive at 
all, and yet be a serious menace to health because it produces 
mosquitoes which are vectors of malaria. And so, if we 
examine a list of things which have been considered prejudi- 
cial to health, we shall find that some have no relation 
to health at all, but are offensive to the senses; others which 
are both offensive and a menace to health, and others 
which are a menace to health but not offensive. The 
health officer must think clearly and reason logically in 
regard to these matters, and not let public clamor lead 
him to spend his best energies and his funds in work 
which will have little or no effect in promoting the public 
health. 
Nuisances. 
Many of these insanitary or offensive conditions are 
classed legally as 11 nuisances.” Anything which is a 
menace to, or dangerous to, health, or is offensive to the 
senses, is a ‘‘nuisance.” Nuisances are of two kinds, public 
nuisances, which affect a considerable number of people, 
and private nuisances, which affect only individuals. 
Public officers may be required to cause the abatement of 
public nuisances, but private nuisances are ordinarily the 
concern of the individual affected. 
There are several methods of abating a public nuisance. 
Always there must be due legal notice served. If, after 
due notice, the nuisance is not abated, the following pro- 
cedures may be instituted: WASTES DISPOSAL, SANITATION AND HOUSING 
119 
1. The nuisance may be enjoined. 
2. The nuisance may be abated by direct action to 
remove or destroy it. 
3. The maintainer of the nuisance may be arrested, and 
upon conviction fined or imprisoned. 
Private nuisance may be handled by the individual 
directly affected, as follows: 
1. He may institute an injunction. 
2. He may sue for damages. 
3. He may directly remove or destroy the nuisance, 
provided he may do so without bringing about a 
breach of the peace. 
As a general rule, the administrative officer will find that 
the most simple and effective means of handling nuisances, 
where the law states that each day of maintenance is a 
separate and distinct offense, is to cause the arrest of the 
offender, and the imposition of a fine, with the notification 
from the judge that further continuance of the nuisance 
will result in a second arrest followed by imprisonment. 
If, however, the local justice of the peace will not cooperate 
with the health officer, then resort must be had to a higher 
court for a temporary injunction, which is made permanent 
after a hearing before the judge. Only in extreme emer- 
gency should the health officer attempt direct abatement, 
and he should consult an attorney to make certain that he 
proceeds legally. Otherwise the health officer may face a 
suit for damages. In general the health officer is advised 
to avoid legal measures except as a last resort, as usually 
one or two notices will bring about abatement. 
Garbage Disposal. 
The matter of garbage and refuse disposal is one that is 
prolific of nuisance complaints in urban districts. In rural 
districts this problem is seldom of importance, as no near 120 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
neighbors are affected. Under rural conditions, garbage is 
easily disposed of by feeding to hogs or chickens, by burying 
or burning. But in towns burning will usually produce an 
immediate nuisance, and ultimately burying may produce 
a nuisance, and hogs are out of the question. Therefore, 
it is usually provided by ordinance that garbage and 
refuse shall be removed from the premises and disposed of 
elsewhere. 
A satisfactory method of handling garbage and refuse 
collection is not always easy to devise. The following 
underlying principles, however, are fairly well defined. 
1. Garbage while on the premises shall be kept in fly- 
tight, water-tight metal containers; other non-decompos- 
able refuse shall be placed in separate containers to prevent 
scattering. 
2. Garbage and refuse shall be removed at regular and 
sufficiently frequent intervals, by designated official col- 
lectors. The removal of garbage must be compulsory. 
3. Garbage shall be finally disposed of in such a manner 
as to prevent nuisance. Usually it is necessary that this 
final disposal be carried on in an isolated place. 
Various methods of disposal are in vogue, and are used 
with more or less success, depending largely upon the 
intelligence with which the methods are applied. If mixed 
garbage and refuse is collected, incineration is usually the 
best method of disposal. Fairly satisfactory types of 
incinerators have been developed. Mixed garbage and 
refuse may be used in filling low areas, if promptly covered 
with a layer of earth. If garbage is collected separately 
from refuse, the garbage may be subjected to a reduction 
process for the extraction of grease, the residue being used 
for fertilizer. This can be done successfully only on a large 
scale. Garbage may also be successfully fed to hogs, if 
reasonable precautions in handling it are used. Hog WASTES DISPOSAL, SANITATION AND HOUSING 
121 
feeding has had an increasing vogue, largely because of 
the utilization of food refuse that would otherwise be 
wasted. Hog feeding can be carried out in a sanitary 
manner, and this method of garbage disposal deserves 
extension. 
The most success in handling the garbage and refuse 
problem has been had where inspectors have been employed 
to make regular and frequent inspections of premises to 
see that they are kept clean and that the garbage and refuse 
is delivered to the collector. The work of collection and 
disposal should be handled by the Department of Public 
Works, or similar official municipal agency, and not by the 
Health Department, for it takes much time and money 
from more important health work. The public does not 
distinguish between degrees of importance, but is likely to 
consider only the total appropriation, a large part of which 
may be consumed by operating a garbage and wastes 
collection system. 
Flies. 
Probably manure disposal offers more real difficulties in 
sanitation than garbage disposal. It is not realized by the 
public that horse manure is responsible for the breeding of 
at least 95 per cent, of the house-fly population of a commu- 
nity. Garbage piles are secondary as breeding places of flies. 
In well-sewered urban communities it is a matter of 
question as to whether the common house-fly is a significant 
factor in the spread of communicable diseases. There is 
equally little question but that in insanitary rural communi- 
ties, especially the unsewered small towns with many open 
privies, the fly is an important factor in disease trans- 
mission. In another chapter we discuss the problem of 
sewerage, and shall not here repeat this subject, except to 
state that by adequate sewage* disposal we practically 122 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
eliminate the possibility of fecal contamination by flies. 
The prevention of fly breeding presents another line 
of attack against fly-borne infection. Since the bulk of 
common flies (Musca domestica) are bred in stable manures, 
it is obvious that manure disposal is essential to the reduc- 
tion of flies. Fly-swatting, fly traps, and fly poisons are 
useful against the few survivors of an effective sanitation 
campaign, but are hopelessly ineffective if fly breeding is 
permitted to go on unchecked. 
Manure should be regularly and promptly removed 
from stables, and disposed of by scattering on land, or 
burning. Dry scattered manure does not breed flies. 
Manure should be removed at least once every four days 
in summer as this is the minimum period of larval develop- 
ment in warm weather. Especial care should be taken 
thoroughly to clean the floors of stalls, as the number of 
fly larvae that will develop in manure lodged in cracks 
and crevices in floors is surprising. Stable floors should 
preferably be made of concrete, with removable wood 
gratings for the animals to stand upon. 
Bins for storage of manure are objected to, as they 
are seldom kept in sufficient repair to be fly-proof. 
They usually become fly incubators. If manure must be 
stored the so-called “ maggot trap ” is preferred. This con- 
sists of a shallow concrete basin, usually 12' X 6' X 8" 
inside dimensions, over which is set a wooden grating, made 
of 1" X 2" strips set 3" center to center on 3" X 4'/ 
supports. The manure is piled on the grating and the 
basin is half filled with water, on which is floated a 
film of crude oil. As the fly maggots reach their full 
larval development, they crawl to the bottom of the 
pile for the purpose of pupating, drop through the grating 
into the basin, and are killed by the oil and water. The 
basin should be flushed occasionally to prevent nuisance. WASTES DISPOSAL, SANITATION AND HOUSING 
123 
A few chemicals, such as borax, have been found fairly 
effective for treating manure to prevent fly breeding, but in 
general such chemical treatment is less certain and more 
expensive than adequate removal and disposal. 
Where flies are at all prevalent, a strong campaign to have 
houses well screened should be made by the local health 
officer. 
Mosquitoes. 
Not only is the mosquito a considerable nuisance, but 
certain species of the genus Anopheles transmit malaria. 
Where malaria is present special measures against Anopheles 
breeding must be taken. The common, or culicine, 
mosquitoes will breed in practically any collection of water 
which stands long enough to permit their development. 
This is about 12 days in mid-summer. But the Anopheles 
mosquito is a bit fastidious in choice of breeding places, 
and selects by preference clear water standing but a few 
inches deep on grassy land. When all such water is 
removed, Anopheles will breed sparingly in other water 
collections, if they are not too foul. 
There are three lines of attack against mosquitoes. 
Drainage is by far the most important, as it removes the 
breeding places. Drainage to prevent mosquito breeding 
requires, however, more attention to small details than in 
agricultural drainage. The filling in of low areas which 
cannot be conveniently drained is a useful complement to 
drainage. 
To supplement drainage operations, the use of oil sprayed 
on the surface of pools of standing water is effective in 
killing mosquito larvae. A medium oil of about 30° 
Baume gravity is generally used. The film of oil shuts off 
the air supply of the larvae, and so kills them by suffocation. 
Oiling should be used as a supplement to drainage 124 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
operations only, as it is not a permanent measure. Oiling 
has, however, been successfully used without drainage, or 
with very little drainage, as a method of demonstrating 
malaria control through mosquito reduction. 
Larvicides, for poisoning the water in which mosquitoes 
breed, have been successfully used on a large scale at 
Panama, but are not adapted to small scale operations. 
The stocking of standing collections of water with top 
minnows (Gambusia affinalis) is becoming increasingly 
popular in the South. The minnow devours the larvae, 
but can operate only where vegetation is kept down. 
Careful screening of houses is a useful measure against 
mosquitoes. Various observations have indicated that 
effective screening is responsible for from 20 per cent, 
to 40 per cent, reduction of malaria incidence. The 
meshes of the screen must run 16 to 18 in the inch to 
be efficient. 
Rodents. 
The recent re-appearance of bubonic plague at various 
Gulf ports, and its endemic presence in central California, 
indicates the importance of rat control measures. The 
three fundamental procedures against rodents are: 
1. Rat-proof building construction, to eliminate rat 
harbors and breeding places. 
2. Measures to cut off the food supply of rodents. 
3. Direct destructive measures against rodents. 
Rat-proof building construction is fundamental to suc- 
cessful anti-rat campaigns. For this purpose adequate 
building codes in cities, to require proper construction of 
all new buildings, is one step. The other step is the rat- 
proofing of existing buildings. The latter comprises 
several features, as follows: WASTES DISPOSAL, SANITATION AND HOUSING 
125 
1. (a) The opening up, or raising, of cellars, basements, 
etc., to permit free access of air, light and dogs and cats; 
(b) concreting or cementing such areas. 
2. The blocking off of run-way spaces in walls, floors, 
ceilings and attics, by wood blocks, cement, or metal screen. 
3. Special protection of food storage rooms or buildings, 
by concrete, or metal screen nailed to wood work. Barns, 
granaries, and warehouses must be thoroughly rat-proofed 
as well as houses. The U. S. Public Health Service has 
prepared standard specifications for rat-proofing of 
buildings. 
Measures to cut off the food supply of rats include 
thorough municipal scavenging, with especial attention to 
the use of covered metal garbage containers. Rubbish 
heaps should be removed by the scavengers to reduce rat 
harbor. Attention should be paid to chicken-yards, 
rabbit pens, etc., to remove surplus food materials. 
Direct destructive measures against rodents include 
trapping, poisoning, fumigating (in ships), the use of 
poisonous fumes (carbon bisulphide against ground 
squirrels), and shooting (in rural districts). Poisoning 
methods are discussed in the chapter on plague. 
An effective anti-rodent campaign will include all of 
these various measures, with adaptations according to local 
conditions. 
Rural Sanitation. 
Certainly in respect of sanitation the small town or village, 
if unsewered, is at a disadvantage as compared with either 
the country or the large city. On isolated ranches the 
contaminated well, the open-back privy, and the big manure 
pile cannot do extensive damage, as the chance of introduc- 
tion of infection from outside human sources is at a 
minimum. 126 
ELEMENTS OF PUBLIC HEALTH ADMINISTERATION 
Whatever communicable disease is spread in sparsely 
settled districts is primarily due to contact, as a result of the 
kindly habit of visiting the sick, so much in vogue. But in 
the small unsewered town the introduction of a single 
typhoid or dysentery case may easily result in a fly-borne 
epidemic which spreads through the community until 
checked by cold weather or exhaustion of susceptible 
material, unless it is taken vigorously in hand and effective 
measures of sanitation are applied. And yet it is not 
necessary for unsewered villages to remain exposed to these 
dangers. In the absence of sewers, fly-proof privies can be 
required by local ordinance, and fly breeding can be reduced 
by a more careful manure and garbage disposal. In some 
of the southern states such rural sanitation movements are 
now being carried out in county-wide units and the results in 
the reduction of typhoid, dysentery and diarrheal disor- 
ders of infants have been striking. Hookworm and malaria, 
two other rural diseases, have also been attacked with 
marked success. 
Housing. 
The question of housing and health is a matter fraught 
with many pit-falls for the unwary in logic. For example, 
we have all heard of ‘Tung blocks,” that is, large tene- 
ments in which there is an excessive amount of pulmonary 
tuberculosis. From such cases there arose the idea that 
house infection was responsible for much tuberculosis, and 
that tuberculosis was a house disease. Superficially, such 
a theory seemed warranted, and it was much agitated, 
especially by social reformers. But a critical examination 
of all the facts has failed to show any causal relationship 
between housing and tuberculosis. Chapin (Sources and 
Modes of Infection, pp. 220-222) gives a brief discussion 
of this subject, and it is particularly well treated by WASTES DISPOSAL, SANITATION AND HOUSING 
127 
Schneider in this “ Shortcomings of Socio-Sanitary Investi- 
gations,” in the American Journal of Public Health, 
January, 1917. If, therefore, no causal relationship can 
be logically demonstrated between housing and tuber- 
culosis, how weak must be the case in respect of other 
communicable diseases. 
The effect of bad housing upon the public health appar- 
ently must lie, if there is any effect at all, in causing people to 
live under an unfavorable environment. But again there 
comes up the question as to whether the bad housing is a 
causative factor, and not a purely secondary feature; that 
is, is not the bad housing merely associated with the genet- 
ically less efficient, economically and hygienically, and 
perhaps to some extent also a result of their habits of living? 
We shall not attempt to settle the question, after raising it; 
but we should warn against dogmatic assertions that may 
not be tenable after critical examination. 
There is this much to be said in respect of the housing 
problem that seems to be justified: overcrowding favors 
closer personal contact, thus increasing the opportunity 
for contact transmission of disease; bad housing may 
result in a lessened opportunity to adopt certain measures 
of personal hygiene, e. g., effective ventilation of sleeping 
rooms and living quarters, and so in a measure reduce 
physical resistance to microbial invasion. Yet Park and 
his associates have shown that the children of the tenements 
have a higher degree of immunity to diphtheria than do the 
wealthier children who are less exposed by reason of their 
better housing and relative segregation. 
On these grounds housing conditions may be considered 
within the scope of the health department, as a secondary 
activity. But the other social phases of the housing 
problem so far outweigh the health phase that as a general 
rule the health aspect of housing may be considered a 128 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
minor matter. Good housing is emphatically to be desired 
upon many grounds of social policy, but as a general rule the 
health officer should simply cooperate with other official 
and private agencies engaged in housing improvement, 
rather than attempt to carry on the work through the health 
department. CHAPTER XV 
MILK 
From a public health standpoint, there is no food so 
important as milk. Not only is it an important, even a 
necessary part, of a child’s diet, and hence an indispensable 
food, but it is also potent for evil, because of its suscepti- 
bility to deterioration and contamination. 
Milk contains carbohydrates, proteins, fats, and mineral 
substances in well-balanced proportions, and its direct 
food value is high. But most important is the presence of 
certain vitamins which promote growth. Because of 
their presence the considerable use of good milk should be 
encouraged in the diet of growing children, and the com- 
munity should see that there is available for its children 
an ample, clean and safe supply. 
Through the lack of efficient supervision, or the necessary 
care (and perhaps by accident, in spite of the best care and 
supervision), milk may become a vehicle in the spread of 
certain communicable diseases. It may become con- 
taminated by a case or carrier of typhoid fever, scarlet 
fever, diphtheria, or septic sore throat, and cause explosive 
outbreaks of these diseases. Or, if unclean and poorly 
handled, it may cause diarrhea or enteritis in children 
(summer complaint). The outstanding characteristic of 
a milk-borne outbreak of disease is its explosiveness. 
Usually a considerable increase in cases is noted within a 
few days. An epidemiological investigation of these cases 
will show that many of them take milk from a certain 
dairy, and if we make a ratio of cases to customers for each 
129 130 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
dairy in town, we find by comparison that this dairy has a 
far higher ratio than the others. 
As soon as this has been demonstrated, immediate steps 
should be taken to check further infections. We may 
either: 
1. Require emergency pasteurization. 
2. Stop the sale of milk from the dairy. 
The first is preferable, unless the supply is already being 
pasteurized, in which case we may conclude either: 
1. The pasteurization is improperly performed. 
2. The milk is contaminated during the bottling, after 
pasteurization. 
3. The milk is contaminated during delivery. 
We can check up the efficiency of pasteurization by: 
1. Time and temperature tests on several batches of milk, 
using a standard thermometer. 
2. Bacteriological examination, for total counts, of the 
raw milk, the milk as drawn from the vat after pasteuriza- 
tion, and the milk after bottling. 
If the pasteurization is effective, the contamination prob- 
ably takes place either in bottling or delivery. 
Merely finding the dairy that is spreading the infection 
is only part of the health officer’s duty. Really to effect 
control, we must find the person who contaminated the 
milk. This may be either: 
1. A. carrier. 
2. A “missed case.” 
3. A case in the prodromal stage. 
4. A recovered case back at work too soon. 
If the outbreak is typhoid fever, we must take Widal 
tests of all employees who do not give a history of previous 
typhoid fever. And from both those who give a history of 
previous typhoid fever, and from those who give a positive 
Widal, take specimens of feces and urine to isolate the MILK 
131 
B. typhosus, thus definitely proving the source. This 
is not always easy, as carriers may be intermittent and 
require repeated examination for their detection. 
If the outbreak is diphtheria, we may take cultures 
(nose and throat) of all employees. If scarlet fever, 
we must question closely for recent symptoms of the disease 
among the employees, being especially on our guard for 
the mild, atypical cases which are so often overlooked. 
With septic sore throat, we must also depend on recent 
symptoms among employees in the dairy or milk plant. 
But in any case we must find the person who was the cause 
of the outbreak, and control him, or we have not suc- 
ceeded in the essential point of the investigation. Until 
he is found, our control is precarious, and he may go to 
another dairy or food establishment and start the trouble 
all over again, as well as cause other cases by direct contact. 
Such contamination of milk supplies may occur with 
equal facility in either a clean, high-class dairy, or a low- 
grade dairy, unless the safeguard of pasteurization is 
provided. Even with pasteurization, we cannot protect 
the public if the bottler or delivery boy is the source of 
infection, unless we have a skilled, active, intelligent 
health officer to ferret out the source of infection, and by 
isolation and proper treatment render the carrier inocuous. 
On the promptness and intelligence with which preventive 
measures are taken depends successful control in such cases. 
The possibility of infection, especially of children, with 
tuberculosis, through the medium of milk from tuberculous 
dairy cows, has led to strong efforts to reduce this danger. 
Our present procedure of requiring that all milk shall be 
obtained from cows free from tuberculosis, as determined 
by tuberculin tests, or else shall be pasteurized, seems to 
meet completely the needs in this respect. Tuberculin 
testing of dairy cattle should be performed by skilled 132 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
veterinarians, and the intradermal and subcutaneous 
tests should preferably be alternated for best results. 
The protection of milk supplies from contamination is 
but part of the duties of a health officer, since by pollution 
with extraneous dirt and filth milk may be greatly deterio- 
rated in quality, with resulting intestinal disorders in 
infants. The fundamentals of sanitation in the production 
of milk are simple in theory, but in practice require that 
capacity for taking infinite pains that is found in but few 
people. These fundamentals are: 
1. Healthy, clean dairy cows. Semi-annual or more 
frequent physical examinations should be made by a com- 
petent veterinarian. If the milk is not pasteurized, the 
tuberculin test should be required at least annually. The 
udders should be washed in clean water before milking, 
and the flanks curried and brushed free from coarse dirt 
and loose hairs. 
2. Clean, healthy milkers, who milk with clean, dry 
hands, and who wear clean outer garments. 
3. The small-top milking pail. 
4. Clean utensils and delivery containers, which must be 
thoroughly sterilized. 
5. Immediate cooling of the milk, after drawing from 
the cow, to 50 degrees F., or lower. 
6. Keeping the milk at or below 50 degrees F., until 
delivered to the consumer. 
7. Prompt delivery of milk after milking. 
8. A separate, clean, screened and well ventilated milk- 
house. 
Some cities, realizing the hopelessness of attempting to 
bring all the milk up to the highest standard, have adopted 
a policy of grading milk. Certain standards for different 
grades are set, and milk classified and labeled according 
to the standard met. The standards are based partly MILK 
133 
on bacterial counts, and partly on sanitation of the dairy 
and milk plant, as determined by the dairy score card. 
The grades are, “inspected,” “Grade A,” and “Grade B.” 
“Certified milk” is milk which is certified as to quality by 
a Milk Commission of a County Medical Society, the 
dairy paying the expenses of certification, which usually 
adds from 2 to 5 cents per quart to the cost of the milk. It is 
not possible to introduce a grading system unless adequate 
inspection and laboratory facilities are available. If, 
however, these are available, a good system of grading is 
valuable and advisable. Without these facilities, it is 
impracticable. The dairy score card is an attempt to evalu- 
ate, and make available for comparative purposes, the vari- 
ous sanitary factors in the production of milk. There are 
two general types: 
1. The Bureau of Animal Industry cards. 
2. The Woodward system. 
In the B.A.I. cards, there are separate score cards for 
dairies, creameries and city milk plants. One hundred 
points are given for total perfection (40 for equipment, 
60 for method), and each individual item entering into the 
production and distribution of milk is given a certain 
number of points if perfect. Each dairy or milk plant is 
rated on each item, according to the relative perfection of 
the methods and equipment, and the sum total is called 
the “score,” which is really a percentage relation to pos- 
sible perfection. The B.A.I. cards score the dairy or milk 
plant, without reference to the final product, whereas the 
Woodward system attempts to score the final product, 
the milk. In the Woodward system there is a score card 
for the dairy, but in addition there are points allowed accord- 
ing to the number of bacteria, amount of butter fat, etc., 
the perfect score being 1,000. This system, while in some 
respects more logical, is more complex, and requires a 134 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
very efficient system of inspection, with thorough labora- 
tory control, for its operation. Few cities use the Wood- 
ward system, though its use is increasing. The B.A.I. 
card is almost universally used, modified slightly, however, 
in some states to adapt it to local conditions. The dairy 
score card, while simple, requires some practical experience 
to enable one to use it correctly, and certain definite rules 
of scoring must be followed to obtain comparable results. 
These detailed rules have been prescribed by the Bureau 
of Animal Industry and various state inspection depart- 
ments. The score card has proved to be an effective means 
of improving dairy sanitation, especially if the scores have 
been published from time to time in the local papers for 
the information of citizens. 
Of all the modern safeguards to the milk supply pas- 
teurization has without doubt been the most effective, 
at least in the large centers of population. While there 
are two general methods in pasteurization, the flash method 
and the holding method, the latter is the process generally 
used and accepted. 
In the holding method, the batch of milk is heated 
quickly to 140 to 145 degrees F.; held to that temperature 
for 30 minutes, and then cooled rapidly to 50 degrees F., 
or lower. By this process, if effectively performed, the 
pathogenic bacteria are destroyed and other bacteria 
greatly reduced in numbers, but the cream line, chemical 
characteristics, enzymes and flavor are not affected. Recent 
work would indicate that the vitamins are injuriously 
affected only when much oxygen is introduced during the 
pasteurizing process, as when the milk is vigorously stirred. 
There are various types of pasteurizing apparatus on the 
market. Probably the most perfect is that which pasteur- 
izes the milk in the bottle, but this is not often used, the 
predominant one being the batch pasteurizer. MILK 
135 
Properly conducted, pasteurization renders milk safe. 
It is not, however, a substitute for cleanliness in production. 
Cleanliness in production and prompt delivery at a low 
temperature must be insisted upon even if a clarifier, 
followed by a pasteurizer, be used. Clarification cannot 
remove filth dissolved in the milk; pasteurization cannot 
deliver a milk of low bacterial count, if the raw milk has 
millions of bacteria. No one likes cow manure in milk, 
even if partially cooked. 
Attempts to raise the standard of a milk supply have 
always been met with the cry that it will increase the cost of 
milk. As a matter of fact, those things which bring about 
clean milk do not cost anything more than intelligence 
and attention to details. Their effect upon the cost of milk 
is slight, if appreciable. But, supposing the cost is increased 
slightly, what are two or three cents per quart additional 
cost, compared with the baby’s life? Campaigns for better 
milk supplies should be directed to the consumer as well as 
the producer; the consumer must know the dangers of cheap 
dirty milk. It is impossible to obtain a perfect milk supply 
by passing an ord nance. It requires hard, steady work 
over a period of years, with constant inspection, labora- 
tory work, and above all, education, both of the dairyman 
and the public. One step at a time should be taken, and 
from five to ten years are usually required to get real 
results. But they are well worth the time and effort. 
Remember, however, that a small, scrupulously clean dairy 
can turn out excellent milk of a low bacterial count, if 
intelligent methods are used, while some dairies with 
expensive equipment produce dirty milk. A certain 
minimum of equipment is essential, but put more trust in a 
clean dairyman’s method than in fine equipment. 
A final word of caution may be given in regard to bacte- 
rial counts in milk. Standing alone, a bacterial count 136 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
means practically nothing. It must be interpreted in the 
light of the conditions of production and distribution. For 
example, a clean but uncooled milk will in a few hours give a 
fairly high count, whereas a refrigerated dirty milk may 
give a fairly low count. Counts are usually higher in 
summer than in winter. A milk delivered locally in a few 
hours after milking will give a much lower count than a 
milk which must be transported a long distance and 
delivered many hours after milking. Furthermore, there 
is always a possible variation of some magnitude between 
separate counts taken from the same bottle, even with a 
careful and uniform technique. Therefore we must interpret 
bacterial counts in the light of the conditions of production 
and distribution, and judge from series of counts rather 
than from single samples. CHAPTER XVI 
FOOD AND FOOD POISONINGS 
From a public health viewpoint, the sanitation and 
general control of food supplies has somewhat complex 
aspects. Unfortunately, in the public mind, our sense 
of aesthetics and of commercial fraud has become rather 
confused with health, and it is not always easy, even 
for the trained sanitarian, to escape from lapses in clear 
thinking and sane action. The situation is further com- 
plicated by the fact that the law has imposed certain duties, 
not necessarily related to the control of disease through food, 
upon the health authorities. 
Whether or not an adulterant, unless poisonous, is 
added to a food product, is of slight public health impor- 
tance. Aside from deaths from poisoning, there is no 
evidence that such adulteration is a significant factor in 
mortality or morbidity. There is, also, no evidence that 
uninspected meat is a significant factor in mortality or 
morbidity, unless eaten raw. And yet we find many health 
departments spending much money, and laying great stress, 
on food analysis and meat inspection, when inspection to 
maintain adequate sanitation of foods, and at least an 
occasional medical inspection of food handlers, is neglected. 
There are, also, health departments which spend more on 
food inspection and analysis than on any other function. 
Almost always this means a neglect, or ineffective perform- 
ance, of essential activities which reach directly the most 
important causes of sickness and death. It is not urged 
that food inspection and control is not a desirable thing. 
137 138 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
But a proper balance, and a proper emphasis on essentials, 
should be obtained in a well-directed public health 
organization. 
The control of the quality of food, and the maintenance 
of food standards, is primarily a function of the federal 
and state authorities. Only the largest cities can attempt 
to do the inspection and laboratory work required, and it 
is preferable that the analytical work be centralized in 
state laboratories for reasons of economy. Foods sold in 
interstate commerce are inspected and analyzed by the 
Bureau of Chemistry of the United States Department of 
Agriculture, which administers the Federal “Pure Food 
Law” (Food and Drug Act of June 30, 1906), and promul- 
gates thereunder the “Food Inspection Decisions” and 
“Service and Regulatory Announcements.” These regula- 
tions prescribe the details of food standards and inspection 
methods. 
In general, state food inspection services, where organized, 
follow closely the rules, regulations and standards of the 
Bureau of Chemistry. Their functions pertain to foods 
sold or manufactured within the state and do not cover 
interstate commerce. 
_ Since meat inspection often becomes a function of local 
health departments, it is advisable that the health officer 
should have a fair working knowledge of the subject, 
although the details of such work should be handled by a 
qualified, experienced veterinarian. All meats which are 
shipped in interstate commerce must first be inspected and 
passed by inspectors of the Bureau of Animal Industry, 
U. S. Department of Agriculture. Inspections are made 
only at approved establishments, which are abbatoirs 
which meet the minimum standards of sanitation set 
by the Bureau. The standards of sanitation, and the rules 
for inspection and condemnation of meats, are set forth in FOOD AND FOOD POISONINGS 
139 
detail in B.A.I. Order No. 211, “ Regulations Governing 
Meat Inspection of the United States Department of 
Agriculture.” These Regulations should be the standards 
of all local meat inspection services. In federal inspection, 
both ante-mortem, and post-mortem-at-time-of-slaughter, 
inspections are required. Animals which are sound and 
free from disease are passed for food. Under some condi- 
tions infected animals may be “passed for sterilization” 
and rendered into lard and tallow. Animals which are 
unsound or extensively diseased are condemned and tanked 
for fertilizer. Carcasses with slight disease involvement, 
as in tuberculosis or actinomycosis, may be passed for food, 
after the infected parts or organs are removed and 
condemned. 
Most of the larger municipalities maintain more or less 
satisfactory meat inspection services, modelled on the B.A.I. 
regulations. Very few of the small municipalities do so, 
and as a result the poorer classes of meats, which would 
not pass inspection, are often sold in small towns. A few 
small towns with active health officers have avoided the 
worst of this evil, without incurring the heavy expense of 
ante-mortem and at-time-of-slaughter inspection, by requir- 
ing that the tongue, lungs and liver be left attached by 
natural tissues to the carcass until inspected, prior to sale, 
by the health officer of the place of sale. 
In respect of the sanitation of foods, which is primarily a 
matter of local inspection, the aim is to obtain a reasonable 
minimum of sanitary conditions under which food is pro- 
duced and sold, and also to limit, as far as possible, carriers 
or cases of communicable diseases as food handlers. The 
subject therefore roughly divides itself into the sani- 
tary inspection of food premises and methods of food 
handling, and the medical inspection of food handlers to 
determine their freedom from communicable disease. A 140 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
third division is that of inspection for unsound or 
unwholesome food, and its condemnation. 
Food sanitation regulations should provide for the reason- 
able protection of foods from contamination during manu- 
facture, preparation, storage, sale and delivery. Food 
premises should be so constructed as to be easily cleaned, 
and to be maintained at all times in a clean condition. 
They must be adequately screened against flies. Adequate 
lavatory and toilet facilities must be provided for employees. 
It is of course essential that these latter be located together, 
and that employees be required to wash their hands with 
soap and water after visiting the toilet. 
Containers and utensils must be thoroughly cleaned 
and sterilized between individual uses, and alternative 
acceptable methods of sterilization stated. Foods must 
be at all times protected against contamination by flies 
and dirt. 
No person having, or suspected of having, a communicable 
disease, should be permitted to work in a food establish- 
ment. The best procedure, undoubtedly, would be to 
require routine medical examination of all food-handlers, 
with initial examinations before entering employment. 
If this amount of work is too great to be undertaken, there 
should be at least a requirement that the health officer may 
exclude from food handling any person suspected of having 
a communicable disease, until such time as a medical exami- 
nation, supported by appropriate laboratory tests, shall 
demonstrate a freedom from infection. 
In another chapter are discussed a few diseases due to 
animal parasites, such as trichinosis, which are transmitted 
by foods, and in other chapters the role of foods in the trans- 
mission of typhoid fever has been pointed out. There 
remains a class of food intoxications or poisonings to be 
considered briefly. 141 
FOOD AND FOOD POISONINGS 
In diseases such as botulism, it is not the action of the 
causative organisms on the human tissues which causes 
the disease, but the action of a toxin, or poison, produced in 
the food by the organism prior to ingestion. Botulism has 
recently come into prominence in connection with the eat- 
ing of ripe olives, but as a matter of fact it has been a known 
disease for many years. It was first commonly spoken 
of as “sausage poisoning.” The toxin of botulism is easily 
destroyed by heat, so that even though the toxin be present 
in food, thorough cooking will destroy it and prevent the 
disease. Avoidance of foods, particularly canned and 
preserved foods, which appear unsound, or smell or taste 
spoiled, is quite advisable. 
There are also other forms of food poisoning which may 
be mentioned. Of such, meat poisonings are probably the 
most common. The flesh of swine affected with hog cholera 
may produce an acute febrile attack with diarrhea. 
Paratyphoid fever is at times caused by infected meats. 
There are also toxaemias occasionally caused by decayed 
vegateble products, especially such as are rich in proteins. CHAPTER XVII 
EDUCATION AND PUBLICITY 
Some one once said that the American people liked to be 
humbugged, and it is also stated that there is “one born 
every minute.” This no doubt accounts partially for the 
street fakir, the fake stock salesman, and the patent- 
medicine vendor. But they get their message over to a 
considerable number of people every year, simply because 
they are clever enough to present their wares so attractively 
that many will buy. 
Everyone is engaged, to a greater or less extent, in selling 
something. It may be a manufactured article, or personal 
service, or information, or a combination of these things. 
Health officials are engaged in selling health, the public’s 
health, to the public, that is, to the people and their elected 
representatives. And wise health officials will do well to 
dress their wares in an attractive garb, and use the same 
keen selling psychology that the patent-medicine fakir 
uses. Of course, the health officer must observe better 
ethics and hold a higher regard for the truth. 
Successful government is dependent upon an intelligent 
citizenship adequately and accurately informed as to facts. 
If the public is to aet intelligently in respect of health 
matters, it must be informed as to the facts, and as 
to the health needs of the community. No one is better 
prepared to give the people the facts than a live, intelligent 
health officer. And if he expects the public to support his 
work, and cooperate with him, he must see that the public 
knows the facts. 
142 EDUCATION AND PUBLICITY 
143 
Education and publicity are two effective weapons in the 
armament of the health officer for his fight against disease. 
By education w'e are not now referring to the education in 
our schools, not even education in hygiene; that is the 
function of the school department. We refer primarily 
to the informing of adults as to the general and specific 
facts in regard to public health, sanitation, infant and 
child hygiene, the prevention of communicable diseases, 
etc. Few of the facts in regard to these matters have been 
heretofore taught in schools, except to limited groups in 
the universities, and owing to the rapid progress of science, 
that which was acquired by the children who are now adults 
may be obsolete. 
There is always an opportunity to present to the people 
accurate and truthful information in regard to public 
health matters. It is the duty of the health officer to do so, 
as a part of his work. Few people have the time or inclina- 
tion to do the extensive reading and study necessary to 
obtain knowledge in regard to these matters, but the health 
officer must do so to keep abreast of progress in his profes- 
sion. However, he does not need to be a literary artist, 
nor an orator, to tell the public about the facts of public 
health. All that is necessary is to say it simply, straight- 
forwardly, in plain English, and at opportune times. 
If a few cases of diphtheria appear in his community, that 
is a very opportune time to tell the public how to prevent 
diphtheria. If in early summer several babies die of intes- 
tinal disorders, that is an excellent time to tell about the 
proper diet and care of children in summer. If one can tie 
up his informative material with a matter of news, it will 
“get over” more effectively to the people. 
There are several channels for education. Newspapers 
are not educational mediums; they are vehicles of news. 
But one can do much educational work with a news item if 144 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
he words the facts to be presented as a part of the news. 
Public lectures are informative, but usually not popular 
because they do not amuse. But if they are made interest- 
ing through the use of moving pictures or lantern slides, a 
good audience can often be obtained. Printed pamphlets 
and circular letters are good, if they get into the hands of 
people who will read them, but a large percentage is ineffec- 
tive because so much of it goes into the waste-basket unread, 
or is filed away to be read at some future time, which may 
never come. 
Paid advertising in newspapers, magazines, bill-boards, 
etc., is especially effective, but few health departments 
attempt it because of insufficient funds. 
The use of placards in public places, card exhibits in the 
corridors of public buildings, bullet’n boards bearing timely 
items of interest, models of sanitary and insanitary privies, 
wells and dairies, together with interesting laboratory speci- 
mens, are all of value in educating the public on matters 
of health and in advertising the activities of the health 
department. 
Don’t forget to talk health at every proper opportunity; 
to friends, acquaintances, the people who come into the 
office, to the school children—especially to the school 
children. Teachers are usually glad to have the health 
officer give short talks, and it is often remarkable what the 
children will take home and re-tell to their parents. But 
have a care to speak with exceeding clearness, or what they 
tell to their parents will be still more remarkable. 
But that is not all that the health officer should do along 
this line. He should let the public know what he is doing 
and why; and what he would like to do, but cannot, and 
why not. In other words, he ought to keep the public 
in constant touch with his activities. This is publicity. 
It is news, and the newspapers will take any reasonable EDUCATION AND PUBLICITY 
145 
amount of it. It is information to which the public is 
entitled, and which it is glad and eager to have. And it 
helps the health officer in several ways. 
In the first place, it shows the public that the health 
officer is on the job and accomplishing things. It is remark- 
able how many people look upon the health officer simply 
as some one to investigate nuisances and tack up placards. 
Many people never come in contact with him except under 
somewhat unpleasant circumstances, when he is “mean” 
enough to restrict their liberties in various ways. But if 
from day to day there appear new items of the various and 
interesting things that every live health officer is doing 
for his community’s welfare, the public soon gains a different 
viewpoint of his work. And if, when his annual or monthly 
reports come out, there is shown a steady reduction in the 
death rate, or a lessened prevalence of communicable 
disease, or so many physical defects of children corrected, 
or a large number of sewer connections made or nuisances 
abated, or improvements in the milk supply, and so on, 
then the public begins to look upon the health officer, not 
as a person to “cuss” over the telephone when on Hallow- 
een Night some small boys drape a dead cat on the gate post, 
but as a live, active, constructive force for community 
progress and betterment. 
As a part of his publicity, as well as for record, the health 
officer should make reports of his work to his local govern- 
ing board, and through them, to the public. He should 
remember, however, that reports serve two purposes, 
records and information. The mistake should not be made, 
as is so often done, of cluttering up a public report with a 
mass of statistics, which no one will read. Make the report 
so attractive in form and interesting in statement that it 
will be read. If statistics must be published, give them 
separately as an appendix to the report. There is much 146 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
money wasted on printing the average health department 
report which is burdened with a mass of statistics. Tell the 
story of what the statistics show, in the report, but if it is to be 
read, leave out the detailed figures. 
One final caution should be given; never overstate the 
case, or exaggerate, or state as a fact something that is 
still in the experimental state, no matter how promising it 
looks. Such exaggeration, if found out (as it often is), 
makes the public doubt other statements, even such an 
established truth as that the Klebs-Loeffler bacillus causes 
diphtheria. The patent medicine fakir can get away with 
it by moving on to the next town, but the health officer has 
to “face the music.” The truth is sufficient. It is 
interesting. It is not necessary to stretch it to get results. 
Truthfulness, Brevity, Simplicity, Attractiveness, are the 
cardinal requirements of all good publicity. CHAPTER XVIII 
PUBLIC HEALTH LAW 
There are a few simple facts as to the legal powers, duties 
and limitations of health officers which can be expressed in 
uninvolved language, and which every health officer ought to 
know as a part of his equipment for his job. 
Most of us have forgotten what we learned in school 
about the Constitution of the United States, so to begin 
our discussion it will be well to recall a forgotten point. 
The Tenth Amendment says, “The powers not delegated 
to the United States by the Constitution, nor prohibited 
by it to the States, are reserved to the States respectively, 
or to the people.” One of these powers, which is reserved 
exclusively to the States, save in exceptional cases hereafter 
referred to, is the so-called “police power.” This power 
authorizes the States to regulate for themselves and their 
own welfare, as they understand it, their purely internal 
and domestic affairs. It is a power designed for the protec- 
tion of the lives/health and property, and for the comfort, 
convenience and safety of their inhabitants, and is the broad- 
est reservation of power reposed in the people. It is 
characterized as an attribute of sovereignty. 
Under this power all manner of restrictions are cast about 
our individual freedom of action, in respect of both our 
persons and property, in order that the greatest liberty and 
safety be assured to all. Public health laws and regula- 
tions are a part of this police power. As has been noted, 
police powers, and therefore health regulations, are reserved 
to the individual action of the several States, in so far as 
147 148 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
they concern affairs within each state. However, when a 
healthmatter is of “interstate” concern, the Federal govern- 
ment has power of intercession, and in purely interstate 
matters its jurisdiction is exclusive. 
As a result of this reservation to the States of the power 
of health regulation, we have no uniformity in either 
methods or effectiveness of public health work, as between 
States. Each state is a law unto itself, and may have just 
as good or just as poor health laws and administration as it 
wishes to pay for. 
It has been generally held by the courts that, since the 
Constitution has reserved this power of health regulation 
to the States, therefore, all health matters are primarily 
State functions, rather than local (county or municipal). 
Intrastate health matters are conceded to be not essentially 
local, but of concern to the whole State. Furthermore, 
the local governments (county or municipal) in most States, 
are simply subdivisions of the State, created by the Legis- 
lature, having only such powers as the Legislature may 
delegate to them. Therefore, while local health officers 
are appointed and paid by a subdivision of the State to 
enforce the laws and regulations locally, they are under 
the supervision and control of the State in many particulars. 
The Legislature may properly prescribe the manner of 
appointment of local health officers, and cause the expenses 
of their work to be a charge against the county or munici- 
pality. This sometimes leads to difficulties and dissentions, 
as local governments often desire to run their affairs with- 
out State interference. But in the end, the necessity and 
propriety of central (State) control over local health officers 
is generally upheld by the courts. 
Under the operation of State statutes, we see three 
principal lines of public health work authorized or required. 
Of course, measures for the control of communicable PUBLIC HEALTH LAW 
149 
disease represent one line. Here we find the requirements 
of notification to the health authorities of the existence of 
cases or the occurrence of deaths, though the latter are 
required to be registered for legal as well as public health 
purposes. We also find the power of inspection of persons 
to determine either the existence of disease or the nature of 
a suspected communicable disease. There is also the power 
of isolation of the affected individual and quarantine of 
persons who have been exposed. 
There are some limitations upon these powers, however. 
For instance, a health officer could not go up to any person 
he met on the street and say “Here, I want to examine 
you.” However, the health officer may enter the premises 
of an individual for the purpose of making an investigation, 
and he may isolate any person, where there is reasonable 
suspicion that such person is affected with a communicable 
disease. Moreover, there need be only a reasonable sus- 
picion for such action. If the person is to be isolated, 
there should be at least a reasonable demonstration that 
he is infected with a communicable disease. A physical or 
laboratory examination should be the foundation of such a 
demonstration. If a person refuses to permit a physical 
or laboratory examination, he may still be isolated upon a 
reasonable suspicion that he is infected with a communi- 
cable disease. If a person is to be quarantined, it must be 
shown that he has been exposed to a case of communicable 
disease, or presumably so exposed, and that it is reasonable 
to suppose that he will shortly develop the disease. 
A person wrongfully isolated or quarantined can obtain 
release by applying to the proper court for a writ of “ habeas 
corpus.” Further, he may sue the health officer for 
damages, if such official has failed to follow the statute, 
and has therefore acted beyond his official powers. Wrong- 
ful isolation is no ground for damage against the health 150 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
officer if the isolation be perfected according to the means 
specified by the statute. So a health officer who acts in 
accordance with the law, and upon reasonable grounds, 
need not fear a suit for damages. Even if he has made a 
mistake, provided that he has done so honestly and without 
malice, and has used reasonable care and skill in his 
diagnosis, the courts ordinarily are not apt to assess 
damages against him. But if he has exceeded his legal 
authority, or has acted without good reason or reasonable 
competency or has been neglectful of the welfare and 
safety of the person isolated or quarantined, the health 
officer is personally liable for damages resulting. The 
city, county or State is not liable for the illegal acts of its 
health officers. If the health officer is prosecuted in a 
criminal case or sued for damages, on account of an illegal 
act, he must pay his own expenses for defense, as the city 
or county cannot legally defend him. 
After communicable disease, comes the subject of 
things which may affect the public health. These matters 
are generally considered legally as “ nuisances. ” A nui- 
sance is, in general, anything which is injurious to health, 
or offensive to the senses, or which interferes with comfort 
and enjoyment of life. We must carefully distinguish 
between public nuisances and private nuisances. A public 
nuisance is anything which affects injuriously a considerable 
number of people. A private nuisance is one that affects 
only one or two people. For example, if John Smith 
established a hog-pen in a New York tenement house, it 
would be a public nuisance, as perhaps several hundred 
people would be offended. But if the same John Smith, out 
in the country, built his hog-pen next to neighbor Jones’ 
house (there being no other farm-houses nearer than several 
hundred yards) it would be a private nuisance. A public 
nuisance may be also a private nuisance under certain con- PUBLIC HEALTH LAW 
151 
ditions. The abatement of nuisances has been treated in 
the chapter on Wastes Disposal, Sanitation and Housing. 
Some things that are generally considered nuisances, as for 
example manure piles or open privies, may be prohibited 
by legislation, and in that case a penalty for maintenance is 
usually imposed. Where a penalty is attached, the best 
method of procedure is to bring a criminal action against 
the offender before a court having jurisdiction. 
Finally, there are various lines of public health work 
which are comparatively modern in origin, and were not 
thought of in the old common law. Such things as school 
medical inspection and the more advanced venereal disease 
control measures, are examples. For these, direct legis- 
lative authority is essential, although this authority may be 
couched in very general terms in defining the powers and 
duties of health officials, or may be given in distinct terms 
and sharply defined and limited. 
Every health officer should carefully study, first, his 
State health laws and regulations, as the principal sources 
of his powers and duties, and should then examine his local 
ordinances. Then he will know definitely his powers and 
his limitations. For his own safety he should know the 
latter as well as the former. It is a good plan to consult 
with the district, county or city attorney occasionally, and 
always to consult him when not entirely certain as to the 
legality of a proposed procedure. 
Litigation should be avoided as much as possible, as it 
is usually an unsatisfactory method of getting results. It 
is best to proceed on the assumption that of course “Friend 
Smith” intends to obey the law, that he has simply 
forgotten that such-and-such is the law, and intends to 
comply at once now that you have reminded him. Once in 
a while, however, one will encounter “Grouchy Jones.” 
Kind advice and words get no results with him. With 152 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
sorrow in the voice, tell him that one would hate to be 
unpleasant and have to cause his arrest, but really one 
cannot play any favorites and let him “get away with it,” 
while all the neighbors are obeying the law. If that does 
not move him, never threaten arrest. If every polite means 
has been exhausted, file a complaint and get a warrant of 
arrest. And once legal measures have been started, go 
through with them vigorously and without compromise. 
It is surprising how much can be accomplished in 
enforcing the law if one uses tact, combined with firmness. 
There will, however, always be a residuum of “tough 
nuts” which can be “cracked” only by legal measures. A 
few successful prosecutions of such cases, especially if 
conducted with dignity and without evidence of personal 
feeling, will greatly raise the public’s estimation of its 
health officer, and make his work, easier and more pleasant. CHAPTER XIX 
THE ORGANIZATION AND FUNCTIONS OF STATE 
AND FEDERAL HEALTH AGENCIES 
Both federal and state health agencies have for their 
aims three general objects to be accomplished: the pre- 
vention of the entrance of disease into the nation or state; 
the prevention of the spread of disease from one state or 
community to another, and the prevention of disease in the 
individual. Usually, the health work in the states is con- 
centrated in one agency, but the carrying out of health 
work by the federal government is divided among a number 
of bureaus in several different departments. For example, 
the federal registration of births and deaths and statis- 
tical work relating thereto is carried on by the Bureau of 
the Census, in the Department of Commerce; food inspec- 
tion and the sanitation of milk supplies are under the 
direction of the Department of Agriculture; and, until 
comparatively recently, the greater part of federal activity 
concerning child hygiene was centered in the Children’s 
Bureau of the Department of Labor, and in the Bureau 
of Education of the Department of the Interior. There has 
been an awakening of late, however, to the need for a 
federal Department of Health, into which all of the agencies 
now dealing with health problems would be gathered, and 
the day is not far distant, perhaps, when such a department 
will be created. Economy and efficiency are becoming so 
urgent, as taxes mount, that the demand for centralization 
of authority and avoidance of duplication and unnecessary 
overhead expense cannot long be withstood. 
153 154 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Health administration in the country as a whole is 
further complicated at present by the lack of uniformity 
in state organizations and laws, resulting perhaps in large 
part from the reservation by the Constitution of the power 
of regulation of health matters, within the states, to the 
states themselves. There has been a tendency for some 
time, however, toward overcoming this lack of uniformity, 
through the efforts of organizations of state health authori- 
ties, the Public Health Service and national agencies of a 
non-official character. 
The United States Public Health Service, which exercises 
most of the health functions of the federal government, is a 
bureau in the Treasury Department. It’was first organized 
in 1798 as the Marine Hospital Service for the medical 
care of seamen of the merchant marine. Later, it was 
assigned the duties of maintaining the national and inter- 
state quarantine service. In 1902, the name was changed 
to that of the Public Health and Marine Hospital Service, 
and in 1912, when additional powers and functions were 
authorized by the Congress, it assumed its present 
designation. 
The organization of the Public Health Service may be 
briefly outlined as follows: 
The Surgeon General 
Division of Scientific Research 
Division of Foreign and Insular Quarantine and Immi- 
gration 
Division of Domestic Quarantine 
Division of Sanitary Reports and Statistics 
Division of Marine Hospitals and Relief 
Division of Personnel and Accounts 
Division of Venereal Diseases 
Inspection Service 
Section on Public Health Education STATE AND FEDERAL HEALTH AGENCIES 
155 
Purveying Service 
Chief Clerk 
The Surgeon General is appointed by the President, from 
the regular commissioned corps, with the consent of the 
Senate, for a term of four years. He has direct supervision 
over the activities and personnel of the entire Service. The 
chiefs of divisions are selected by the Surgeon General, 
from among the commissioned personnel, and have the 
title of Assistant Surgeon General while on special detail 
as chief of division. 
The functions exercised by each division of the Service 
are as follows: 
1. Division of Scientific Research. Laboratory and 
field investigations of man and domestic animals; includes 
the Hygienic Laboratory at Washington. The research 
work performed includes not only communicable diseases, 
but also occupational diseases, pollution of streams and 
coastal waters, rural sanitation, sewage disposal, child 
hygiene, and control of the manufacture of serums, vaccines 
and pharmaceuticals. 
2. Division of Foreign and Insular Quarantine and Immi- 
gration. The prevention of introduction into the United 
States of communicable diseases from foreign countries, 
through examination of immigrants and passengers on vessels 
or trains, at points of entry. 
3. Division of Domestic Quarantine. Interstate traffic 
and migration of diseased persons; plague suppressive 
measures on the Pacific Coast and in the Gulf States; 
water supplies used in interstate traffic; sanitation of 
National Parks, and cooperates with state and local health 
authorities in suppression of epidemics. 
4. Division of Sanitary Reports and Statistics. Col- 
lects, tabulates, interprets and publishes morbidity data 
from the various states, and from foreign countries. 156 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
5. Division of Marine Hospitals and Relief. Maintains 
the various marine hospitals of the Service, for the care of 
disabled seamen. 
6. Division of Personnel and Accounts. Detail and 
assignment of officers, and the accounting work of the 
Service. 
7. Division of Venereal Diseases. Federal allotment to 
states for cooperative venereal disease control work; 
educational measures against venereal diseases. 
8. General Inspection Service. Inspection of Service 
and Contract hospitals. 
9. Section on Public Health Education. Publication 
and distribution of public health pamphlets, press releases, 
lantern slides, etc. 
10. Purveying Service and Chief Clerk. Purchase and 
issue of supplies and equipment; records; mails and files; 
communication. 
While we have seen that the federal Public Health Service 
is distinctly limited, by the Constitution, as to matters 
within the states, yet the states themselves, as to their 
health powers within their own borders, are practically 
unrestrained, except by general limitations of the common 
law, or special restrictions imposed by the constitution of 
the state. This power of the state is supreme over both 
cities and counties, as such political subdivisions are as a 
rule merely creations of the state, established by statute, 
and their powers and duties may be modified, enlarged or 
taken away by act of the legislature. All local health legisla- 
tion (municipal or county), therefore, is subordinate to 
state health legislation, unless otherwise provided in city 
charters. 
Very generally, for the sake of uniformity of procedure 
and effect, the states have established some means of cen- 
tralized control over the health affairs of local communities, STATE AND FEDERAL HEALTH AGENCIES 
157 
and also a uniform system or code of health laws and regu- 
lations. But, inasmuch as a constant stream of new 
facts and discoveries are being added to sanitary science, and 
because statutes are inflexible and not easily changed, the 
states have found it desirable, in many cases, to have the 
legislature pass acts giving only broad powers and duties to a 
subordinate board, usually termed the State Board of 
Health. 
Such boards can meet more often than the legislature, 
may be selected for special knowledge of public health 
matters, and so may legislate, by means of regulations 
made within the limits permitted by statute, more intelli- 
gently and more in detail than it would be possible or 
expedient for the legislature to do. The details of their 
regulations can be readily changed to keep pace with new 
scientific knowledge or new conditions. The functions 
of such boards are therefore quasi-legislative, and also 
usually quasi-judicial, in that these boards usually have 
power to hear and decide complaints, appeals and petitions 
in respect of the public health. 
Often such boards have executive functions as well, but 
this is bad administrative practice. Lord Bacon truly 
said “There be three parts of business: the preparation; 
the debate or examination; and the perfection. Whereof, 
if you look for dispatch, let the middle only be the work 
of many, and the first and last the work of few.” This 
ancient truth is well exemplified in our corporations 
which, while they entrust the general policy of the corpo- 
ration to a board of directors, nevertheless place the 
responsibility for getting results on one man, the general 
manager. 158 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
State Boards of Health, having executive functions, often 
delegate the duty of administration to one of their members, 
who is generally called the secretary. But the best plan, 
from an administrative standpoint, is to have the executive 
office separate from the board. In New York this has been 
carried to the logical extreme by having the Commissioner 
of Health the actual head, and the Board merely advisory 
to him. 
The functions of state health departments are often, 
as are the functions of the federal Public Health Service, mis- 
understood, even by some who are employed in the work. 
The legislatures have usually, and with wisdom, required 
each local community to enforce health laws and regula- 
tions within its jurisdiction. If the state were to attempt 
to carry on the details of local work from a central office, 
three untoward conditions would arise: first, the necessary 
general direction and supervision would be hampered or 
even overwhelmed by a mass of details; second, local 
interest and responsibility would be weakened or destroyed; 
third, there would be danger of inflexibility and inadapta- 
bility to varying local needs and conditions. 
The real purpose of a state health department should 
be to supply a means of securing uniformity, within 
reasonable limits, and efficiency of local health adminis- 
tration; to supply expert direction to local health adminis- 
tration; to provide for those health matters which local 
communities cannot effectively handle, or which affect 
the interrelation of local communities; and to anticipate, 
meet and cope with emergencies. 
The principal functions of state health departments may 
be grouped as follows: 
1. Direction and Supervision of Local Health Officers. 
2. State Registration, Analysis and Interpretation of 
Vital Statistics. STATE AND FEDERAL HEALTH AGENCIES 
159 
3. Promulgation of Uniform Health and Sanitary Regu- 
lations. 
4. Investigation and Control of Epidemics. 
5. Supervision of Water Supplies, Sewage and Wastes 
Disposal, Housing and other Sanitation. 
6. Supervision of Food Supplies. 
7. Maintenance of Public Health Laboratory Facilities. 
8. Promotion of Maternal, Child, Infant and School 
Hygiene. 
9. Special Investigations into Health Conditions and 
Causes of Mortality and Morbidity. 
10. Public Health Education and Publicity. 
11. Expert advice to local communities on public 
health matters. 
12. Point of Contact for Cooperation with Outside 
Agencies, as*the National Red Cross, National Tubercu- 
losis Association, U. S. Public Health Service, etc., and 
for Reciprocal Relations with Other State Health 
Departments. 
A few of the above points may be briefly expanded. 
1. Direction and Supervision of local Health Officers. 
It is highly desirable that local health officers be subject 
to reasonable control and direction of the state health 
authority, for best results to the state as a whole. This 
can be accomplished to some extent by requiring through 
statute that local health officers shall enforce within their j uris- 
diction all state health laws and regulations, and all orders 
of the state health executive. And if the state health 
department can be kept out of politics, it is advisable to 
have appointments and tenure of office subject to approval 
of the state health executive. This latter provision 
helps to prevent the appointment of incompetents, and 
to remove the drones and ineffectives. 160 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
2. State Registration, Analysis and Interpretation of 
Vital Statistics. 
Unless administered from a central state office, the 
registration of births, deaths, marriages and morbidity 
would be irregular, uncertain and usually inadequate. 
Furthermore, local communities are unlikely to obtain 
personnel trained in the analysis and interpretation of 
these data, outside of large cities. 
3. Promulgation of Uniform Health and Sanitary 
Regulations. 
It is of the utmost importance that at least in general 
outlines the health and sanitary regulations should be 
uniform over an entire state. If each community were 
permitted to adopt its own regulations the confusion would 
be great indeed, and what is permissible in one town 
might be forbidden in an adjacent city. Certainty and 
uniformity in these regulations is both desirable and essen- 
tial for successful health administration within a state, and 
is of benefit to the local community as well as to the state 
as a whole. 
By an exchange of information and the results of practical 
application of regulations, in time we should obtain a 
substantial uniformity between the several states, which 
will be a distinct gain in health administration. 
4. Investigation and Control of Epidemics. 
Theoretically, local health departments should pre- 
vent epidemics. Practically, through present conditions 
of inadequate funds and lack of properly trained per- 
sonnel (as well as fortuitous circumstances beyond 
reasonable control) epidemics do get started, and if of 
large proportions may spread beyond the ability of local 
health departments to control. The state health depart- 
ment should be able to mobilize its resources promptly 
for local assistance in such cases, and should thoroughly STATE AND FEDERAL HEALTH AGENCIES 
161 
study each outbreak to obtain information by which similar 
outbreaks in the future can be prevented; to advance 
general epidemiological knowledge, and to train its own 
personnel and the local health officers to a greater prac- 
tical effectiveness in emergencies. 
5. Supervision of Water Supplies, Sewage and Wastes 
Disposal, Housing and other Sanitation. 
Much of this work is of a specialized technical nature, and 
local communities (as a rule) cannot employ the skilled 
personnel necessary. Also, these problems are often 
of an inter-community nature. For this reason the state 
should maintain the necessary staff of specialists, whose 
services are freely available to the local communities in 
solving their individual problems. 
Especially in respect of the engineering phases of public 
health work, where large expenditures may be involved, 
and often where there are inter-community relations, the 
state health department should have a large measure of 
control and the final approval of any project should rest 
with it. 
6. Supervision of Food Supplies. 
For the benefit of the producer especially, but also for the 
ultimate benefit of the consumer, food regulations should be 
uniform, and enough supervision of local enforcement 
officials should be had to see that they are enforced in a 
uniform manner. 
7. Maintenance of Public Health Laboratory Facilities. 
The larger municipalities and counties should maintain 
adequate diagnostic laboratories in the local health depart- 
ments, for the more common examinations. The state 
should maintain facilities for those portions of the state 
not so served, and in addition should handle special 
examinations such as rabies, Wassermans, etc., and should 
conduct laboratory investigations in rare diseases. 162 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
8. Promotion of Maternal, Infant, Child and School Hygiene. 
This can only be effectively developed through the local 
health and school authorities, but the state should assume 
the general direction and stimulation of the local communi- 
ties, and should aid them with exhibit material, literature, 
and special lecturers. It can also find its greatest usefulnes 
in making the broad plans for a campaign and in enlist- 
ing the active cooperation of other governmental agencies. 
9, 10,11 and 12. These functions are evident by their titles. 
The emphasis which will be placed upon each of the 
functions will be determined by various conditions. Pri- 
marily they should be determined by a careful and intelli- 
gent study of the vital statistics of the state and its various 
subdivisions. 
Above all else, the state department of health should be 
the agency which anticipates the health necessities and 
emergencies of the state. Through the assemblage and 
interpretation of reports and statistics, it should have 
available *at all times accurate information as to the past 
and present health conditions of the state. From these 
it should not only determine present needs, but also future 
requirements, and especially should, as from a watch tower, 
spy danger from afar, warn of impending outbreaks, and 
set control machinery in operation before an epidemic or 
other danger has an opportunity to begin its deadly work. 
Such dangers seldom materialize without warning. Intelli- 
gent study of adequate information will show the signs of 
danger in time to take measures, just as properly corre- 
lated business statistics give warning to the keen business 
executive of the tendency of trade and finance. Few states, 
if any, have attempted as yet to fulfill this function, and 
none as yet has attained any conspicuous measure of success. 
This is a development of the future which is pregnant with 
possibilities for good. CHAPTER XX 
PUBLIC HEALTH AND SOCIAL WELFARE 
Every one who uses terms should be placed under the 
necessity of defining and limiting them accurately, so that 
his hearers may know exactly what he means. We feel 
that we ought to be under the same necessity in using the 
much abused term “ Social Welfare,” but plead guilty 
to an inability to da so in a manner satisfactory either to 
ourselves or to the so-called “social workers.” It would be 
a rash definition which would place a limitation upon 
something which has not yet developed toward a point of 
limitation, for much social welfare wmrk still seems to be 
groping in the dark toward objectives as well as methods. 
But for our purposes, a very general and by no means accu- 
rate definition of social welfare work is the sum of all those 
collective activities of human society which have as their 
purpose the improvement of the living conditions of indivi- 
duals or families in their relations with society as a whole. 
Under such a definition, it is obvious that both education 
and health are included, as well as many other things. 
When we consider the various factors which affect 
directly or indirectly the public health, we begin to realize 
that public health is more or less inter-related with a 
number of other social phenomena. Whether we reason 
deductively from a generalized definition, or inductively 
from a number of observed phenomena, we are brought to 
the conclusion that public health is an integral and essen- 
tial part of the public welfare. 
Let us consider a few of the social factors related to public 
health. Economic condition is believed to exert a marked 
163 164 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
effect upon the public health. One prominent health 
worker has stated that probably the greatest single factor 
in improving the health of the nation would be a doubling 
of wages. Of course this is an economic fallacy, as a 
doubling of wages would mean a material increase in money, 
and therefore in prices, without increasing the nation’s 
real wealth. But the statement indicates a frequently 
held opinion. Another statement, which has been promi- 
nently made in recent years, is that as the family income 
increases, the infant mortality rate decreases; the inference 
is that poverty is the cause of infant mortality. 
But because two phenomena occur at the same time, it 
is not proof that one is cause and the other is effect. The 
real cause may be something else. It is very doubtful 
indeed if poverty is in itself the fundamental cause of excess 
sickness or mortality. For example, English statistical 
experience has shown that the group of agricultural laborers, 
which is about their lowest paid class, is apparently one 
of the healthiest groups in the nation. Statistical investiga- 
tions of family groups have shown a striking relation between 
longevity in parents and a low infant mortality rate in their 
children, this relation holding true even under conditions 
of extreme poverty and hardship. 
Therefore, it is not safe to make too positive a statement 
in regard to economic condition and public health. The 
two seem to have some relation, but a direct relation of 
cause and effect is not proven. Economic condition is 
probably of indirect influence, in that poverty may compel 
people to live under distinctly unfavorable environmental 
conditions. 
We have many racial and national groups in our polyglot 
population. A study of these groups reveals the fact that 
certain diseases are more virulent in some of these groups 
than in others. This is both a social and a health problem 165 
PUBLIC HEALTH AND SOCIAL WELFARE 
of great interest. As an example, take tuberculosis. 
Its mortality is much higher among the negroes and 
Indians than among the whites (Hoffman has shown 
that for the Navajo tribe it is approximately ten times the 
rate for whites in the Registration Area). As we indicate 
in the chapter on “Heredity and Health,” this is probably 
due to the longer racial experience of the white race with 
the disease, and the consequent survival of the more resis- 
tant strains; the native races not having had so long an 
experience, the process of natural selection is proceeding at 
a more rapid rate. 
The same phenomenon may be observed, with the rela- 
tive racial positions reversed, in respect of certain tropical 
diseases, such as malaria, for example. The colored 
races are relatively rather tolerant of infections which are 
highly virulent in the whites. 
In the field of infant mortality investigations have shown 
that there is a differential mortality between the children 
of native-born mothers and of foreign-born mothers, and 
that the rates vary to some extent in the different national 
groups. How far this may be due to racial hereditary 
factors, and how far to factors of national custom, has not 
been determined, but here is a social and health problem 
of interest. 
Alcoholism may, in the future, cease to be asocial problem. 
In the past, it has been at times advanced as a health 
problem, and there is ample evidence that the considerable 
use of alcoholic beverages has had a detrimental effect on 
health. But the controversy on moral and economic grounds 
has obscured the hygienic aspects of the matter, so that the 
effect on public health of this social phenomenon has 
never been sufficiently realized by the public. 
Prostitution is another social phenomenon the public 
health importance of which has only recently begun to be 166 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
appreciated. The evidence that it is an important, if not 
the principal, source of venereal disease, is almost over- 
whelming. We are referring, of course, to commercialized 
prostitution, without necessarily including all sexual promis- 
cuity. Previously, prostitution has been attacked and 
defended only on religious, social and criminal grounds. 
But it is now being treated as a health problem of the first 
magnitude, and we are beginning to see visions which 
indicate that ultimately the public health viewpoint and 
method of attack may conquer this ancient evil. Perhaps 
nothing else shows so well as prostitution the close inter- 
relation of other social factors with health. Considered 
simply as a moral issue, the fight against the evil has not been 
productive of great result until public health methods were 
brought to the attack. As a corallary, possibly we shall not 
obtain material success with some of our health problems 
unless we consider the various social factors involved. 
We have passed through that stage of human develop- 
ment when the sources of communicable disease were 
believed to be in our environment. We are now beginning 
to place the proper emphasis on man himself as the source 
of the diseases of man, without neglecting those environ- 
mental conditions which have an important bearing on the 
communication of disease from one individual to another, 
or which affect the susceptibility or resistance of the indivi- 
dual. A reference to fly-borne typhoid, malaria, plague, 
hookwork disease and pneumonia is sufficient to make clear 
our meaning. We have succeeded in more exactly evaluat- 
ing environmental’factors. But have we yet considered 
that environmental conditions may be essentially due to 
social and economic factors ? Have wre properly taken those 
factors into account in handling unsatisfactory environ- 
ment ? There is apparently a vast amount of indeterminate 
illness and reduction of physical efficiency which is related PUBLIC HEALTH AND SOCIAL WELFARE 
167 
to defective environment. It is doubtful if any real pro- 
gress can be made in treating such illness until the adverse 
environment is corrected. Few realize the vast amount of 
mere palliative medical treatment which is made utterly 
useless because the patient must still remain subject to 
unfavorable environmental conditions. Here we find medi- 
cal, social and health problems closely interrelated. 
Gradually, our more progressive sanitarians are realizing 
that public health cannot be most effectively considered 
apart from other matters of public welfare. We are 
beginning to use the methods of applied social service, by 
trying to reach the individual directly with teaching and 
demonstration, through the mediums of health clinics, 
health centers and public health nurses. But most of us 
have yet to realize that communicable diseases are but a 
part of the whole problem of public health, and that an 
adequate health program must reach the fundamental 
causes of mortality, ill health and reduced physical efficiency. 
The final step will be to coordinate all social welfare work, 
including public health, for the reason that there is an 
interdependence of the various parts, and the greatest 
result for the least expenditure requires correlation of 
effort. 
All this may seem strange doctrine to many who have 
heretofore considered public health to be a matter of purely 
medical aspect. But medicine itself is really a social 
service. The conception of public health service has so 
broadened in recent years that its purely medical phases 
are now considered of secondary importance. 
Yet, while we should recognize the larger social aspect of 
public health work, and correlate health activities with 
programs of social welfare, there is a danger that the pendu- 
lum will swing too far in the opposite direction. We 
must guard against submerging public health work in a 168 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
mass of other welfare work. There has developed a ten- 
dency for social welfare workers to usurp the proper 
functions of health departments. This tendency is par- 
ticularly noticeable in the field of child hygiene wherein, if 
successful, it would take away nearly one-third of our 
opportunity of reducing the general death rate. 
The reason for this usurpation has, in some instances, 
been the failure of the health authorities to measure up to 
their opportunities or their duties. There has been, to 
some extent at least, a failure due to an inadequate and not 
sufficiently comprehensive program. This condition will 
not be remedied, unless health officials develop a wider 
social vision. We need very badly to develop techincal 
expertness among health officers, but still more do we need 
the development of sanitary statesmanship. When our 
health officers are selected and appointed because they are 
broadly educated as well as intensively trained in public 
health work, then our health problems will be studied as 
social problems, not as narrow medical problems, and logical 
and effective preventive measures will be applied. There is 
a vast accumulation of public health knowledge not utilized 
for lack of a broad program and sufficient leadership for 
making it effective. When our health officers generally 
recognize the social aspects of public health work, then will 
there be comprehensive programs of health improvement 
applied under inspired leadership. The possibilities of 
success are perhaps beyond even our dreams, but the hope 
of today may become the accomplishment of tomorrow. CHAPTER XXI 
THE FUTURE OF PUBLIC HEALTH 
Until recent years, public health practice has paralleled 
closely the evolution of medicine. A long struggle with 
“miasms” ended rather sharply with the discoveries of the 
early bacteriologists. Their work threw a brilliant light 
upon the etiology of infectious disease, which had lain 
shrouded in a haze of conjecture. Gradually the con- 
ception took form that as a source of infection, man was 
more important than his environment, and it naturally 
followed that the control of the case, the carrier and the 
vector, together with methods of immunization, became the 
chief concerns of health officials. In order to safeguard 
the welfare of the community, government assumed an ever 
increasing supervision over the conduct of the individual 
as it might affect his fellows, and today we find the broadest 
possible power conferred upon health authorities to delve 
into intimate details of personal conduct, as well as to 
regulate communities en masse. With a better under- 
standing of some of the factors involved in disease pro- 
duction it has quite logically followed that early preventive 
measures should supplement those of suppression only. 
First by private enterprise and later by government, there 
have been developed those activities that make up a large 
part of modern health work, such as child welfare, prenatal 
care, school hygiene and life extension. Even more 
advanced is the experiment now being conducted on a 
national scale in England, that of health insurance with all 
of its possibilities for complete preventive and curative 
169 170 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
medical care for the individual. Observing the trend of 
events in the history of public health practice and stimu- 
lated by the rapidly growing interest of the scientific and 
lay world in such matters, we can safely outline some 
of the next steps that should be taken, as well as venturing 
a look into the more distant future. 
Birth, death and morbidity returns are fundamental to 
any modern health program, yet the states in the Regis- 
tration Area are required to attain only 90 per cent, of per- 
fection. What of the other 10 per cent.? Until every case is 
reported, until every birth and death is recorded, these statis- 
tics, that are truly vital, will lack the complete accuracy they 
demand. Furthermore, when certificates of birth and 
death continue to come to the desks of registrars with 
every essential item missing or grossly irregular in form, 
there is obviously vast room for improvement at the very 
foundation of our health work. It is not too much to 
expect that the well trained physician of the future will 
take as great pains with his reports as he does with his 
diagnosis or his operative technic; for he will have been 
taught an appreciation of the real value of vital statistics. 
Control of communicable diseases marked the starting 
point of public health practice. Through the years knowl- 
edge has increased, until epidemiology now assumes the 
dignity of a science. Yet influenza, measles and scarlet 
fever, to name a few examples, baffle the skill of the health 
officer. An enticing field of research into these undis- 
covered realms awaits the investigator of the future. Day 
by day the pathologist adds to his store of isolated facts, 
but the science will eventually produce a genius who will 
formulate those fundamental laws that are needed to 
explain the observed phenomena and to open up wider 
fields of investigation. Intensive and extensive research 
in bacteriology and pathology must be continued if we are THE FUTURE OF PUBLIC HEALTH 
171 
to gain a better understanding and control of infectious 
diseases. 
Thanks to concentrated study, our knowledge of the 
veneral diseases has reached an advanced stage of develop- 
ment. They have been examined not only from the 
standpoint of pathology and epidemiology, but from that 
of sociology, of psychology, and of ethics, as well. The 
next generation should see a marked diminution in the 
ravages of these world-old infections. It is a challenge to 
our coming health officers that they cannot ignore, for they 
have the tools at hand with which to mitigate this scourge. 
Everywhere we see figures that point to growing morbid- 
ity and mortality from accidents. While much has been 
accomplished in the industrial field, a sudden accession of 
business activity is usually marked by a high accident rate. 
In the streets of our cities life is held too cheap. If the 
modern health officer is to measure up to his duty of 
reducing all preventable mortality, he must join with the 
safety engineer and the traffic director in attacking this 
urgent problem. 
No phase of public health activity makes such popular 
appeal as the preservation of infant life. The right of every 
baby to be born well and to acquire vigor of mind and body 
is nowhere denied. Yet the lowest infant mortality rate is 
still well over thirty. Coordination of agencies for pre- 
natal care, maternal nursing and child welfare will do much 
to reduce this mortality to a minimum. But there is needed 
also a better understanding of those factors that influence 
the prenatal and puerperal states and of their effect on the 
infant. 
Leaving the subjects that have received our principal 
attention, during this developmental period, let us examine 
that fertile and untilled field—the chronic, degenerative 
diseases. Here we find over 25 per cent, of our mortality, 172 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
and practically no effort being made to cope with it. Dr. 
Theobald Smith has recently said, “Since science is valued 
in proportion to its value to predict successfully certain 
events, medical science will be judged by the way it takes 
hold of a new phenomenon to determine its etiological ante- 
cedence. If, in the course of its development, it has failed 
to take cognizance of factors necessary to build the science 
into a consistent whole, it should retrace its steps and make 
up the deficiency.” 
While the class of affections just mentioned cannot be 
considered as new phenomena, they have certainly been 
neglected by medical science in its preoccupation with those 
problems that offered a more ready solution. Yet the 
health officer cannot afford longer to disregard this hiatus 
in the continuity of his work. What has been done for 
disorders of the heart by Sir James Mackenzie1 must be as 
carefully evolved for other chronic conditions and we 
must go even further, if a real conception of the “eti- 
ological antecedence” is to be achieved. Such an under- 
taking is n'ot so formidable as it may appear. Agencies 
similar to the Life Extension Institute and the great insur- 
ance companies might unite in a thoroughgoing study of a 
large group of persons from the commencement of prenatal 
life until death, keeping in constant touch with each indi- 
vidual, minutely recording every phenomenon of his 
growth and moribdity, examining him at frequent inter- 
vals for the least departure from “normal.” With this 
mass of data in hand, it would be possible to evaluate the 
etiological significance of symptoms that are now over- 
looked or disregarded. Thus the physician and health 
officer could predict the onset of disease that is not now 
recognized until it has produced a gross pathology. The 
1 Mackenzie, Sir James: The Future of Medicine, Oxford University 
Press. THE FUTURE OF PUBLIC HEALTH 
173 
next step would be to correct the conditions that were 
responsible for the early symptoms; in other words, to attack 
the disease in its curable stage or to prevent it entirely. Is 
this asking too much, if preventive medicine is to be true 
to its name? 
The same procedure might well be adopted in an attempt 
to discover and eliminate the immediate and remote 
sequelae of acute infectious disease. At present we have 
little information upon this important phase of public 
health. Dr. Isaac A. Abt has expressed the thought in 
his paper on “Sequelae of the Communicable Diseases of 
Childhood as a Public Health Problem.” He says, “It 
is possible that the public health officer is interested in the 
sequelae of disease because whatever tends to the pro- 
duction of chronic invalidism, whatever deteriorates the 
health of citizens or incapacitates them for their normal 
vocations, may affect the physical, moral or mental status 
of the people, and may become an economic, a social and a 
state problem which would call for the most thoughtful 
consideration of public health officials.” 
Increasing difficulties beset the public health engineer, 
as our population becomes more dense. Abundant pure 
water and ample sewage disposal at moderate cost are 
problems that are pressing for solution. Not only are the 
large urban areas involved, but the rural and semi-rural 
districts are becoming more thickly settled,with the con- 
sequent question of effective sewage disposal growing more 
insistent. Cheap and efficient standards, suited to varying 
conditions, must be worked out and vigorously applied. 
An open privy should become a matter of public concern in 
any community. How far from this ideal is the average 
American village of today! 
Concentrated populations increase immensely the diffi- 
culties and expense of food-handling. For the city dweller 174 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
of small means to secure a properly balanced diet is a serious 
tax upon his income. Especially is this true regarding 
milk of wholesome quality. It must be the concern of 
health authorities to cooperate with other agencies that 
are striving to secure adequate and safe food supplies 
for all classes of the community. Undernourishment, 
with its train of ills, is a constant finding among the school 
children of the land, lowering, as it does, the physical 
and mental average of our citizens. Coupled with better 
food supplies must go popular education in the composition 
and preparation of foods and a better public understanding 
of the requirements of the body in this respect. Who is in 
a more advantageous position to give this information than 
the officials who are charged with the care of the public 
health? 
As an illustration of the lead that is often taken by non- 
official agencies in initiating a public health movement, we 
find that the greater part of the present agitation for 
a better understanding of mental hygiene is fostered by 
persons not directly connected with organized health work. 
If our ideal citizen is one who has health of both body and 
mind, it is high time that the health officers of the country 
became more familiar with this subject. It is not enough 
to stop with the physical examination of a school child. 
His mental tendencies should come within the general 
survey and those that are indicative of mental disease 
should receive as careful attention as his adenoids and 
tonsils. 
To those engaged in the work it is quite evident that 
public health administration in its broadest sense is a 
highly specialized profession. The medical man, with no 
other training than that received in the average medical 
school, is no more equipped to assume immediately the 
duties of an efficient health officer than to become at once THE FUTURE OF PUBLIC HEALTH 
175 
a finished surgeon or an ophthalmologist. The so-called 
courses of “hygiene” in many of our medical schools are a 
waste of time. There is not even a hasty survey of the 
field and the student emerges witlYa hazy idea that public 
health and hygiene consist in the measuring the cubic 
feet of air in a room and perhapsJn the making of a few 
perfunctory reports. Yet the layman looks to the physi- 
cian as mentor in all matters of health and sanitation. 
Is it any wonder that the public should fail utterly of 
comprehension? Our physicians must be given a broader 
outlook in the schools. Adequate courses in the whole 
subject of public health must become the rule, where they 
are now the exception. And these newer physicians must 
assume the role of teachers, combating ignorance and 
superstition with sound scientific fact. Thus aided, the 
health officer can carry his message to the public, knowing 
that it will not be neutralized by uninformed and mis- 
leading dogma from the professional men of his community, 
but rather that the public will have added faith in his 
teaching and will demand of him a high quality of training. 
A natural sequel to enlightened public opinion should be 
the removal of public health administration from the blight- 
ing effects of petty politics. No man of professional attain- 
ments cares to hold office through such means. If qualified 
officials are to be had, their tenure of office must be secure 
and their operations unhampered by politicians of the 
narrow sort. 
Thus briefly have we sketched the next immediate steps 
in the realm of public health. Some are already in the way 
of fulfilment, others are taking form, while a few are only 
here and there engaging the thought of earnest students. 
It remains to examine the present trends in public health 
practice in order to gain, if possible, an intimation of 
developments that may be expected in the future. Are we 176 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
dealing adequately with the whole subject, or are we touch- 
ing it at a few points only? Do we meet the problem of 
cure as well as prevention in anything like an effective 
manner? Is not the actually sick man of as much interest 
to the health officer as the potentially sick one? If so, is 
our present attempt to maintain an artificial demarcation 
between the two bringing us nearer to the kind of service 
that the state should render? If not, should the state 
undertake to treat as well as to prevent? England is 
already tending that way and there is agitation for some- 
thing of the same sort in this country. De we not need a 
new definition of the proper functions of governmental 
health agencies* which will indicate clearly the bounds 
within which such work shall be done? If public health 
practice has for its chief aim the reduction of mortality to 
its lowest terms, can the sick be left to haphazard care; 
can they be ignored by the health officer? Should he 
not have supervision over the physical wellbeing of man- 
kind from the cradle to the grave, if he is to perform the 
highest service to the community? These questions are 
demanding answers in the growing complexity of our civili- 
zation, with its higher ethical standards. That they will 
be answered in the not distant future is certain. The health 
officer must share in their solution, or suffer the consequences 
of his indifference. 
While not existing in a necessarily causal relationship to 
sickness, poverty is largely associated with it. Any 
measure that reduces poverty increases the ability of the 
sick to procure adequate care. The economic status of his 
community must, therefore, engage the attention of the 
health officer and enter into the consideration of better- 
ments. Underlying poverty is the inherent capacity of the 
individual, which determines to a large extent the economic 
plane to which he will attain. A keen appreciation, there- THE FUTURE OF PUBLIC HEALTH 
177 
fore, of the principles of eugenics must be a part of the 
future health officer’s equipment, if he is to fulfill his whole 
duty to the state. 
The future of public health rests with the younger men 
and women who are now in our schools or who are just 
entering upon their careers. Are they receiving a broad 
vision of the possibilities that await them, or is it being 
crowded out with infinite detail? The wealth of a nation 
consists in the vigor of its men and women. Are future 
health officers being trained to conserve and develop that 
wealth upon which the survival of our nation rests in the 
coming struggles of man to possess the world? 178 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Hodified FRon Whipple's Figure 
To Vict/m 
Insects 
CONTACT 
Foods 
Water 
Mill K 
Source5 and Nodes of Infection 
Preventive Measures 
From Patient 
DlAGRAn HI PART II 
THE PREVENTABLE DISEASES PRELIMINARY CONSIDERATIONS 
At the outset, one should become familiar with that 
sonorous word which delights the ear of the sanitarian, 
“epidemiology,” literally, the study of epidemics, or the 
investigation of the nature, causes, modes of transmission, 
and control, of the communicable diseases. Armed with 
these data, the health officer is prepared to attack with 
certainty the problem at hand. Without them, he is firing 
in the dark, much as the medical empiricist applied his 
shotgun prescription. 
In commencing his investigation, the health officer 
frequently makes the mistake of not confirming the diag- 
nosis of a fellow physician. Ethical considerations becloud 
the conception of his obligation to the public. As a 
result, his subsequent course of action may be set at nought 
and an outbreak may develop, through failure to determine 
the true nature of a disease and to take proper control 
measures, when most effective. It is the duty, as well as 
the right, of the health officer to satisfy himself as to the 
diagnosis of any case that may come to his attention and 
to act upon his own conclusions. 
Once the nature of a communicable disease has been 
established, it is essential that the characteristics of the 
specific organism, if identified, should be clearly in mind. 
For the physician-health officer who finished his medical 
training in earlier days a short review of the principles 
of bacteriology will reveal many of the underlying reasons 
for modern public health practice. 
Knowing the nature and cause of the disease, the query 
should be, “How did it originate?” To the uninformed 
181 182 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
a case of infection often appears to arise spontaneously, 
without reference to anything else in the environment. 
We know, of course, that this cannot be true, for it is a 
fundamental law of bacteriology that most of the patho- 
genic micro-organisms must have a suitable host. Exposed 
to air, sunlight and drying, they perish rapidly. The 
theory of so-called “air borne” infection has been discarded 
in the light of modern bacteriology. Furthermore, when 
the source of infection and mode of transmission of such 
diseases have been carefully and accurately worked out, 
some human being, or animal, has always been found at 
the bottom of the trouble. While we do not know the 
specific organisms of some infectious diseases, as measles, 
scarlet fever or smallpox, yet their obvious communica- 
bility, coupled with the fact that carefully studied epi- 
demics have usually disclosed the human or animal origin, 
lead us to the safe conclusion that they are of the same 
nature as those affections already solved. Furthermore, 
when we apply similar methods of control to them, they 
yield as readily. 
What, then, are the possible sources of infection? (1) 
A sick patient, if there be one about, naturally comes to 
the mind, first of all. But often the solution is not so 
simple. (2) Many persons are so resistent as to show 
few outward signs of illness and even to be unaware of 
such a condition in themselves, beyond a slight malaise. 
Such ‘ * missed cases ” are a fruitful source of infection in others 
and give the health officer no little worry. (3) Even more 
elusive is the “carrier,” the person who has no symptoms 
of disease whatever, who may be in robust health, but who 
is harboring within himself the infective organism. One 
writer has said that modern public health practice dates 
from the recognition of the carrier. Such a one may, 
or may not, have had an attack of the disease which he is PRELIMINARY CONSIDERATIONS 
183 
spreading. In some cases the carrier condition is easily de- 
monstrable, as in diphtheria and typhoid fever, while in others 
it is merely a good working hypothesis. The experienced 
health officer will be always on his guard for the carrier. 
(4) Far more insidious than the attack of the human 
carrier is that of the insect that bears pathogenic micro- 
organisms on or within its body. In this class malaria, 
yellow fever and plague have counted their victims by the 
millions. However, we must bear in mind that the ulti- 
mate source of infection lies in some human being, with the 
exception that plague may pass from rat to rat, as their 
fleas seek new pastures. While insects are usually regarded 
as merely channels, or “ vectors,” of infection, yet, for 
practical purposes, they may be classed as sources com- 
parable with the healthy human carrier. (5) In a small 
group of diseases, animals are the original source of infec- 
tion, as in rabies and anthrax. (6) Lastly, food gives rise 
to cases of poisoning, such as have received widespread 
publicity of late. 
Logically, the next question for the health officer to ask 
himself is, “How did this disease travel from its original 
source in some other person, or animal, to the individual 
who is now sick?” It will be found, however, in practical 
application, that the sequence is often reversed. The mode 
of transmission is first determined and the source of infec- 
tion then discovered from the accumulated evidence. 
As a frontispiece to this Part will be found a figure 
adapted from an original sketch by Prof. G. C. Whipple 
(Diagram III). This presents quite graphically the 
avenues of infection and some of the barriers that may be 
erected across the paths. Degrees of importance in these 
lines of transmission are indicated by the lengthening arcs, 
with the straight line of “contact” taking the central and 
most important position. When we consider the mass of 184 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
mild and missed cases of disease, often far exceeding the 
recognized typical cases, and when we add to these the 
many carriers that often arise in the course of an outbreak 
and from association with the sick, there should be no 
surprise at the established fact that contact surpasses 
all other modes in the transmission of infection in the 
majority of diseases. By contact is meant not only the 
direct, intimate association of well and sick, but the indirect 
transference of fresh infective material on the hands of other 
persons and upon inanimate objects. Note that the word 
fresh is used advisedly, for we must not confuse this impor- 
tant means of transmission with the discarded idea that 
various objects may hold the “contagium” in a dessicated 
state and for long periods of time. It is evident, then, 
that in most outbreaks of infectious disease, contact, 
direct or indirect, will explain their spread. Incidentally, 
it should be noted that the characteristic of an outbreak 
propagated in this manner is its comparatively slow develop- 
ment, as contrasted with the explosiveness of the usual 
massive infection resulting from contaminated milk or 
water. 
Of second importance is insect transmission, which may 
be divided into biological and mechanical types. By the 
former it is meant that the infective organism must undergo 
a necessary part of its life cycle, usually a phase of sexual 
reproduction, before the insect is capable of transmitting 
the disease. On the other hand, flies may carry bacteria 
on their feet or proboces and deposit them on food, although 
the fly plays no part in the life cycle of the organism. While 
more varieties of disease are spread by contact, probably 
a greater total of cases, the world over, arise from insect 
transmission. 
Water borne infection has long been recognized, but its 
relative importance is often exaggerated. The first thought PRELIMINARY CONSIDERATIONS 
185 
of the uninformed, in the presence of typhoid fever, is that 
the drinking water must be polluted, while he overlooks 
entirely the convalescent case, or the carrier of long stand- 
ing, in his kitchen. 
Milk is frequently contaminated in the process of pro- 
duction, or in its preparation for the market. The charac- 
teristic of both water and milk borne outbreaks is their 
sudden onset, occurring, as a rule, among a large group of 
persons simultaneously. In a milk borne outbreak the 
largest percentage of cases will be found among the cus- 
tomers of one dealer, which will lead directly back to a case 
or carrier on the dairy. Outbreaks of typhoid fever, diph- 
theria and scarlet fever are frequently traced to such a 
source. Other foods handled by cases or carriers are some- 
times the means of transmitting infection. Uncooked or 
underdone meats often contain living parasites. 
The transmission of bacterial disease by air or by fomites 
has been repeatedly demonstrated to be highly improbable. 
When one considers the difficulty experienced by bacteriolo- 
gists in maintaining living cultures of pathogenic organisms, 
it is scarcely reasonable to contend that such bacteria could 
exist, much less multiply, for long periods of time, when 
exposed to the effects of drying, light and changes of tem- 
perature. Experimental evidence, together with epidemi- 
ological data, have demonstrated that these two alleged 
means of disease transmission have little foundation in fact. 
One can, of course, point to the exceptions in anthrax and 
tetanus. However, both of these diseases are caused by 
spore-bearing organisms, which places them in a class apart 
from other pathogens. One might also mention hookworm 
disease, but here again is a specialized organism that is quite 
distinct from the ordinary pathogenic bacteria. 
In all of the foregoing, such materials as garbage and 
weeds have been ignored. Even the ubiquitous tin can is 186 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
missing. But the reason should now be clear. Aside 
from the garbage pile as a breeding place for flies, such 
things play no part in disease transmission, however 
unsightly or offensive they may be from the esthetic stand- 
point. While weeds sometimes offer a shady resting place 
for the mosquito, it will do no good to mow the lawn in 
order to suppress a typhoid epidemic, notwithstanding the 
convictions of many substantial citizens. If the time and 
money spent on “clean up” campaigns could be devoted to 
securing proper sewage disposal, safe water and screening 
for every home, infinitely more good would be accomplished 
for the public health. 
To sum up in a word; emphasis should be placed upon the 
fundamental conception that it is PERSONS, NOT 
THINGS that are of primary importance in the origin and 
spread of infection. 
In the figure under examination we have so far disposed 
of the central cord and group of arcs denoting modes of 
transmission. It remains to discuss the two sets of con- 
centric circles which represent, on the one hand, control of 
the case or carrier and, on the other, means for protection 
of the well person. Since it is persons, not things, that 
interest the sanitarian in his attempt to control disease, 
modern public health practice throws a number of barriers 
about the person who is sick, or who is harboring pathogenic 
organisms in his body, in order to close the avenues of 
disease transmission that have already been considered. 
These barriers may vary in nature, according to the line of 
transmission peculiar to a particular disease, but are founded 
upon the basic principle mentioned. 
If preventive machinery is to be set in motion, the 
health officer must know of the existence of a case or carrier. 
Notification, then, is the first step in control and the effi- 
cient health officer will bring to bear every means of educa- PRELIMINARY CONSIDERATIONS 
187 
tion, persuasion and law enforcement to secure complete 
and immediate reports of notifiable diseases. He is also 
interested in obtaining adequate medical care for the sick, 
in order that they may be under better control and may be 
rendered non-infective as quickly as possible. 
A plea must be entered here for more careful and accurate 
diagnosis of the communicable diseases. As has already 
been said, there are many more of the mild, atypical cases 
than of the easily recognized types, in most outbreaks. 
Physicians should be led to realize that, from the “text 
book” case to the person with practically no physical signs, 
almost any combination of mild or acute symptoms may be 
encountered and that no little diagnostic acumen is often 
required to arrive at a correct conclusion. The health 
officer ought to take the lead among members of the 
medical profession in stimulating a more careful study and 
revision of prevailing conceptions of communicable disease 
symptomatology. Furthermore, if a diagnosis remains 
obscure, after careful consideration, it should be borne in 
mind that “it is better to be safe than sorry.” Duty to 
the public demands extraordinary watchfulness and an error 
on the safe side will never call forth the charge of neglect 
of duty. When in doubt, a provisional diagnosis and isola- 
tion as “suspected smallpox” or “suspected diphtheria” 
are better than to allow an “influenza followed by chicken- 
pox,” or a “tonsillitis,” to roam at large. 
The remaining measures of control, so far as the patient 
or carrier is concerned, are isolation of the person, as 
thorough as may be required by the nature of the case, 
together with whatever is necessary in the way of concur- 
rent disinfection of discharges, secretions and of articles 
soiled with them. Disinfection is accomplished by burning 
or boiling the infective material, or by subjecting it to the 
action of chemical agents or steam under pressure. Espe- 188 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
cially important in bedside precautions is the instruction 
to the attendant as to proper cleansing of the hands, so 
that infection may not be conveyed to others in the 
household. 
Outside of the sickroom, but within the house, certain 
measures must be taken. If the disease under isolation is 
one that can be carried by insects, the latter must be 
thoroughly exterminated, before they have opportunity to 
invade the sickroom. If the discharges from the patient 
and the utensils which he uses are not completely sterilized 
at the bedside, this becomes a task for the household. The 
health officer should give explicit instructions on the 
proper procedure and see that it is carried out. 
As a matter of self-preservation, the community is inter- 
ested in thoroughgoing control of the infected individual. 
To this end, it establishes health departments and spends 
greater or less sums of money, for the sole purpose of throw- 
ing barriers about the case of communicable disease. Aside 
from the functions of maintaining isolation and quarantine, 
the health department should make epidemiological investi- 
gations of all cases of communicable disease. In this 
connection laboratory tests are often needed, so that the 
provision of such facilities is an important duty of health 
departments. Since schools are a common breeding ground 
of infectious disease, school medical inspection should be 
demanded by every progressive community. In certain 
diseases one of the effective control measures is to treat the 
patient in order to render him non-infective as quickly as 
possible. This is well illustrated by the modern method 
of handling venereal diseases. Free clinics for such cases, 
as well as for tuberculosis, have become a part of recognized 
public health machinery. 
Not satisfied with “watchful waiting,” for disease to 
appear, the community goes farther, by attempting PRELIMINARY CONSIDERATIONS 
189 
to block those channels through which infection may gain 
entry. This brings us to the right hand group of circles in 
the figure. Here the sanitary engineer finds a fertile field in 
providing safe water supplies, protected from possible 
pollution, or freed of such contamination by chemical and 
physical means. He also devises systems for the disposal of 
human wastes in such manner that their menace to the 
community is eliminated. His place is one of fundamental 
importance in the health department of every state and 
of all large cities. 
As information on sanitary matters has become more 
general, protective measures against the introduction of 
disease have been almost unconciously adopted in the home. 
Screening, proper sewage disposal and greater care in the 
selection and preservation of foods, may be cited as 
illustrations. 
Hand in hand with home and community sanitation, 
better personal hygiene has become a powerful factor 
in reducing the incidence of communicable disease. 
Through vaccination, smallpox has diminished markedly 
in many localities, while the typhoid fever rate of the Army 
speaks for the efficacy of prophylactic vaccination against 
the latter infection. We are also learning to avoid personal 
contact with the sick, although many of our rural com- 
munities still leave much to be desired in this respect. 
Thus briefly have been noted the lines of transmission 
for the communicable diseases and the barriers that are 
erected in their way. Many of these topics will be given 
more detailed consideration in subsequent chapters. There 
remains for this general survey a discussion, in outline, 
of the practical ways in which these control measures may 
be applied to various types or modes of disease transmission. 
It has been pointed out that contact is responsible for 
the spread of more varieties of disease than is any other 190 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
single agent, and that contact may be of two kinds, direct 
and indirect. Also, it was shown that the infective 
material must be fresh to be really dangerous. Super- 
ficially, then, it would seem relatively simple to cut the 
line of communication in direct contact by isolating the 
case or carrier. However, as in the case of rabbit stew, 
“you must first catch your rabbit,” so the isolation of 
the offending individual will often lead the health officer on 
a long hunt. However, upon his intelligent energy and 
persistence will depend the early control of many out- 
breaks. Together with the isolation of the case goes the 
quarantining of those who have been in contact with it, 
until the incubation period for the disease has passed. 
It should be noted that a distinction is made between 
isolation and quarantine; the former applying to the 
infected individual or the carrier, and the latter to the 
restriction placed upon contacts, which may be much less 
rigorous than isolation. In fact, the stringent quarantine 
of earlier days has been considerably modified, of late, due 
to the application of data derived from epidemiological 
research. 
An important safeguard against indirect contact is con- 
current disinfection, together with a thorough cleansing 
of the nurse’s hands. Complementary to concurrent 
disinfection is terminal disinfection, which is merely the 
same process applied at the conclusion of the illness. If 
the former has been faithfully done, this latter measure is 
superfluous, but gives the health officer an opportunity to 
assure himself that proper disposal of fresh infective 
material has been made. 
Some may ask why nothing has been said of the old 
standby, fumigation. For many years, this “incense 
has risen to false gods,” due to the theory of fomites 
transmission and to the idea that the gaseous agents, as PRELIMINARY CONSIDERATIONS 
191 
commonly used, were really destructive of bacteria. 
Investigation has disposed of fomites as agents in the 
propagation of disease. It also has been demonstrated 
that pathogenic bacteria are not completely killed by these 
gases, when employed under the usual conditions. Thus, 
there is no need of fumigation, since the bacteria will usually 
have died off in their unfavorable environment, and the 
ordinary application of fumigation is entirely ineffective, 
if any such organisms should remain. This measure 
may as well be abandoned, then, for it often engenders a 
false sense of security which encourages the neglect of 
procedures that will be of real value in eradicating the few 
bacteria remaining in an attenuated form. 
While contact spreads more varieties of diseases, it has 
been stated that insects are the agents in producing far 
greater numbers of cases, the world over. Merely to 
mention malaria, yellow fever, plague and typhus, will 
make the fact obvious. Destruction of the breeding places 
of insects and other vermin is the ideal method of combating 
such diseases as they carry, but is not always feasible. 
However, insects can be prevented from reaching an 
infected individual by screening, by killing those that have 
gained entrance to the premises and by delousing measures. 
Furthermore, insects already infected can be denied access 
to healthy persons by the same means. In this connection 
fumigation has its real mission in the destruction of insects 
and vermin. 
Water was considered in a separate chapter, so that it 
will suffice here merely to mention the fact that sterilized 
discharges, proper sewage disposal, a water supply uncon- 
taminated, or protected by filtration and chlorination if 
necessary, and the boiling of drinking water, when under 
suspicion, will eliminate pathogenic micro-organisms which 
it might otherwise convey. 192 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Another chapter deals with the care of milk, from source 
to consumer, in which the subject of disease transmission 
through milk is covered. Other foods are given more 
detailed discussion elsewhere. 
Thus, in the most cursory manner, an attempt has been 
made to outline the fundamentals upon which modern 
sanitary practice is based. Many ideas have been sug- 
gested which may seem entirely too radical, to those whose 
studies have led them into other fields of science. Before 
taking exception to these propositions, however, the student 
is urged to examine the evidence upon which they are 
founded and to discover for himself that sanitary science 
has kept pace with medicine in its trend from empiricism 
to experimental investigation. A list of references will 
be found in the appendix. 
Since this is not intended as a treatise on the practice 
of medicine, but as a simple guide for health officers, no 
large amount of space will be given to many aspects of 
disease which are important only to the medical attendant. 
As diagnosis concerns the health officer, points of differen- 
tiation will be stressed, when important. In addition, 
the principal topics discussed will comprise the infective 
agent, immunity, modes of transmission and administra- 
tive control. In passing, one term should be explained 
that will be used frequently, viz., ‘‘droplet infection.” 
Diseases are not carried in the air, as that phrase is usually 
understood, but in a more restricted sense they are so 
transmitted, by a spraying into the air immediately 
surrounding the patient of the infective organisms which 
are found in the nose and throat. Persons within a few 
feet receive this spray, whenever the patient laughs, 
sneezes, coughs, or talks forcibly. Demonstration of this 
fact has been made by exposing culture medium at various 
distances from the subject and, later, indentifying growths ANTHRAX 
193 
of mouth bacteria upon it. These organisms ride upon 
the fine droplets of moisture thrown out and may so travel 
for at least ten or fifteen feet, before settling to the ground 
where they begin at once to dry and become inocuous. 
1. ANTHRAX 
Infective Agent.—Particular interest attaches to the 
specific organism, bacillus anthracis, for the reason that 
it was the first bacterium to be definitely connected with 
an infectious disease as the causal agent. It was discovered 
by Pollender in 1849, and in 1860 Davaine presented to 
the French Academy of Sciences his evidence which 
directly associated the bacillus with the disease. Koch 
and Pasteur, in 1877, isolated the organism in pure culture 
and the science of bacteriology was there firmly established. 
The bacillus is one of the spore-bearers, which partly 
accounts for its persistence. It is also quite adaptable, 
growing at temperatures between 12 and 43 degrees Cent. 
Under 14 and over 43 degrees it does not form spores, 
nor can it do so in an atmosphere devoid of oxygen. This 
has a practical bearing upon the disposition to be made 
of infected carcasses. Lack of oxygen also explains the 
absence of spores in bacilli from lesions. 
Incubation Period.—In man the incubation period is 
quite brief, initial symptoms usually developing within 
24 hours after infection. For the intestinal type of 
infection, frequently encountered in animals, the period is 
slightly longer, due to the fact that only the spores can resist 
digestion. 
Immunity.—So far as known, no natural immunity to 
anthrax exists in man. Artificial immunity in animals 
has been induced by means of attenuated cultures, but has 
not been tried on human subjects. Cats and dogs are 194 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
rarely affected, but cattle, sheep, hogs, rabbits and guinea 
pigs are susceptible in varying degrees. 
Modes of Transmission.—Man ordinarily acquires 
anthrax by handling infected hides, hair, wool or carcasses. 
Recently a number of cases have arisen from the use of 
new shaving brushes containing spore-bearing bristles. 
Occasionally a person may receive the spores in food or 
inspired air, but this mode of infection is infrequent. The 
organism gains access to the subcutaneous tissues through 
minute abrasions or larger wounds of the skin. 
Animals are more commonly infected through the diges- 
tive tract by eating food bearing spores. The resulting 
intestinal form of disease spreads to all parts of the body 
before death. 
Diagnosis.—External anthrax assumes two forms in 
man, the malignant pustule and malignant edema. In 
the former case a small furuncle develops that grows to 
large proportions quite rapidly, with a central necrotic 
area and surrounded by an extensive edema. Tempera- 
ture may be elevated or may not rise noticeably. More or 
less toxemia develops and is probably the cause of death 
from the pustule. Malignant edema presents no single 
point of activity, but the disease spreads rapidly through 
the subcutaneous tissues producing extreme edema and 
toxemia. 
Internal anthrax is more difficult to diagnose in its early 
stages, as the symptoms are not characteristic. Either 
the lungs or intestines may give evidence of an acute 
inflammatory process which may be mistaken for other 
conditions. 
Reliance should be placed upon repeated microscopic 
examinations of discharges or scrapings from lesions. The 
bacillus is quite characteristic in appearance and, once 
seen, clinches diagnosis. In addition, culture media should ANTHRAX 
195 
be inoculated with presumably infective material, as 
growth can be secured in 24 hours at 37° C. If doubt still 
exists, inoculations of discharges into mice will produce a 
rapidly fatal infection. 
History of probable exposure to hides, hair, wool or 
infected carcasses should always be sought in any suspicious 
case of furuncle, edema, pulmonary involvement or acute 
intestinal disease. 
Methods of Control.—Every animal that dies of anthrax, 
or of suspected anthrax, should be completely destroyed, 
preferably by burning. If this is not possible, the body 
should be buried at a depth of at least six feet, in order to 
prevent access of oxygen and to secure a temperature 
unfavorable to spore formation. Infected hides are danger- 
ous and should not be sold. Hair and wool from infected 
animals should be sterilized by steam under pressure, or by 
boiling, before they are handled. 
All discharges from lesions in man, whether external or 
internal, should be sterilized by burning or boiling. During 
the acute stage, patients should be isolated, although 
the chances for transmission from man to man are rather 
remote. 
A health officer receiving a report of a case of anthrax 
should immediately investigate to determine the source 
and should see that the animal or infective material 
involved is safely disposed of. 
Mortality.—Only 28 persons died of anthrax in the regis- 
tration area of the United States in 1916. Properly treated 
the disease is not extremely fatal. However, Scholl has 
recently pointed out that surgical treatment of external 
anthrax may do more harm than good and has entered a 
plea for more conservative handling of cases. Thera- 
peutic serum, if used promptly, seems to modify the course 
of infection favorably. 196 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
2. BERIBERI 
Beriberi is a disease primarily of the nervous system, a 
polyneuritis, or multiple peripheral neuritis. Its principal 
features are disturbances of motion and sensation, edema or 
atrophy, and, frequently, sudden heart failure. Geograph- 
ically it is confined almost entirely to those nations which 
subsist chiefly upon rice. In the United States it is found 
among Orientals of the Pacific coast region. 
Cause.—The combined observations of many investiga- 
tors have demonstrated conclusively that beriberi is pro- 
duced by a long continued deficiency in one or more of the 
so called “accessory food substances,” or vitamins. Such 
elements occur, among other places, in the polishings of 
rice, cast off during the second stage of milling, when the 
pericarp of the grain is lost. 
In 1883 the Surgeon General of the Japanese navy came 
to the conclusion that a monotonous rice diet was responsi- 
ble for the high incidence of beriberi among the personnel 
under his care, of whom one-fourth were so affected. By 
reducing the rice issue and adding other foods he was able 
to eliminate the disease entirely and it has since been 
practically unknown in this group. 
Rosenau quotes a convincing experiment conducted by 
Fraser and Stanton: “ These investigators took 300 Japanese 
laborers into a virgin jungle, where they occupied new and 
sanitary quarters. After excluding the existence of beri- 
beri by a careful examination of each person, they were 
divided into two parties of equal numbers. One party 
received polished rice as the staple article of diet, while the 
other party received undermilled rise with pericarp. In 
three months beriberi appeared among the members of the 
party receiving polished rice. When a certain number of 
cases had been noted, polished rice was discontinued and BERIBERI 
197 
thereafter no cases occurred. No sign of the disease 
appeared among the party receiving undermilled rice.” 
To make the experiment more conclusive, the two parties 
were reversed in respect of their diet and beriberi was again 
produced among those receiving fully milled rice. The 
disease has also been cured, when not too advanced, by 
feeding rice polishings or by adding other food substances 
containing the proper vitamin. 
Diagnosis.—The symptoms of beriberi are quite similar 
in many ways to those of arsenic poisoning, especially in 
that form of beriberi known as the dry or paraplegic type. 
The second type is accompanied by a marked edema of the 
extremities, which may be the only, or the most prominent, 
symptom for quite a while. A third type is recognized, 
which is a combination of the other two. In nearly all cases 
there is involvement of the heart, which frequently prevents 
even the lightest of exercise. The disease tends to grow 
progressively worse and death may occur suddenly, at any 
stage, due to heart failure. 
Prevention.—Since deficiency in certain food elements 
is the cause of beriberi, its prevention obviously lies 
in supplementing a too monotonous diet by such food 
substances as contain the missing ingredients. Milk, 
fresh meat, fresh or dried legumes, are all rich in the 
necessary vitamins and are almost equally effective in 
preventing the incidence of the disease. 
A method that has been tried with some success is the 
imposition of an excessively high tax upon completely 
milled rice, which forces the use of the undermilled variety. 
Final elimination of the disease rests upon persistent 
education in dietetics for the populations affected. 
Mortality.—No definite statistics of beriberi mortality 
can be cited. At the Culion leper colony deaths were 
reduced more than 300 a year by proper feeding and the 198 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
resultant disappearance of beriberi. The case fatality 
rate is said to range from 5 to 30 per cent. 
3. CHICKENPOX 
Chickenpox needs to be considered largely to differentiate 
it from smallpox. It has no mortality and is of extreme 
mildness. However, loss of time from school, especially 
in extensive outbreaks, is of sufficient importance to 
demand active control measures. 
Infective Agent.—The infective agent is unknown, but 
is apparently carried in the secretions of the mouth and 
nose and in the exudate from lesions of the skin. 
Incubation Period.—Incubation is usually limited to 
between 14 and 17 days, but may be as short as 10, or as 
long as 20 days. 
Immunity.—In children the susceptibility is high, but it 
diminishes with advancing years. Adults are occasionally 
attacked, although much less frequently than would appear 
from reports of alleged cases of chickenpox in those over 
eighteen. Schamberg states that he saw 25 adult cases in 
the course of eight years of wide experience. A report of 
chickenpox in an adult should always arouse the suspicion 
of the health officer and lead to an investigation as to the 
vaccination history and symptoms. 
Modes of Transmission.—The disease is disseminated, so 
far as we know, in the same manner as smallpox. 
Diagnosis.—Differential diagnosis is stressed in the 
discussion of smallpox. A few points should be emphasized, 
however. 
1. There is practically no prodromal stage. 
2 The rash develops suddenly. 
3. Distribution of the rash is characteristic.—It usually 
appears first upon the trunk, although sometimes develop- 
ing primarily on the face. There is an even distribution on CHOLERA 
199 
the face and trunk, no particular areas being shunned, as 
in smallpox. It diminishes in amount as we pass down- 
ward along the extremities. 
4. The rash passes through all stages in a few days. 
5. Successive crops of lesions appear for about a week, 
any given area of skin will bear the rash in all 
stages of development. 
6. The vesicle is easily ruptured with the finger. 
7. True umbilication is not present, but a depression 
may be found in some vesicles, due to escape of fluid. 
8. Subsequent pitting is rare. 
9. Recent successful vaccination is good presumptive 
evidence against smallpox. 
10. When in doubt as to diagnosis, always treat the 
disease as smallpox. 
Methods of Control.—Isolation of the patient and con- 
current disinfection should be practiced. The secretions 
of the mouth and nose, together with exudates from the 
lesions, should be destroyed, as in smallpox. Children 
exposed to a case of chickenpox should be excluded from 
school for a period of fourteen days. Again let us empha- 
size the necessity of investigating reported cases of the 
disease in adults. Careful control of chickenpox cases 
will eliminate the chance of smallpox gaining much headway 
in a community. 
Mortality.—There is no mortality from the disease. 
4. CHOLERA 
In many of its epidemiological aspects cholera resembles 
typhoid fever quite closely: infection is taken in by the 
mouth; it is passed out with the dejecta; it is transmitted 
by water, and is acquired by receiving into the digestive 
canal fecal matter from some person who has a case or is a 
carrier of the disease. 200 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Within the memory of the older generation in this 
country several nation-wide epidemics of cholera occurred. 
The disease is prevalent continuously in many parts of the 
far East and, to some extent, in the Pacific islands. Yet not 
a case has developed in the United States during the last 
25 years. Such a record is a magnificent monument to the 
diligence of our maritime quarantine authorities who have 
discovered many cases at their various stations and have 
thereby prevented foci of infection from developing in this 
country. So accustomed have we become to look upon 
cholera as a relic of the past that we often overlook the 
fact that it is constantly on our doorstep. 
Another fact that lends interest to this disease is that it 
was the first in which the carrier condition was recognized 
and demonstrated to be an important public health problem. 
Infective Agent.—In 1883 Koch discovered a minute, 
curved bacillus that he could show was constantly found in 
the discharges of patients suffering with cholera. Repeated 
observations of others have confirmed this finding and it 
has been further established as the causal agent by acci- 
dental infection of laboratory workers with resultant produc- 
tion of the disease. The bacillus has been variously termed 
the Koch bacillus, cholera bacillus and vibrio cholerae. It 
is actively motile and non-spore forming. Drying and 
sunlight kill it quickly, but in water it can survive for 
several days, unless the water is highly polluted with other 
organisms that crowd it out. Milk also offers a good 
culture medium, for a short while, but the lactic acid bacilli, 
as they develop, destroy the cholera organisms. It has 
never been shown to grow in soil. As with the typhoid 
bacillus, we can say that the vibrio cholerae is primarily a 
human parasite. 
Incubation Period.—Incubation does not extend, in the 
majority of cases, over three days and may be as short as CHOLERA 
201 
one. Occasionally it has been known to be delayed for a 
week. 
Immunity.—Immunity acquired by an attack of the 
disease is effective, but of short duration. Several methods 
of producing immunity by vaccination have been tried 
with varying success. The most promising of these 
employs four milligrams of an agar culture, killed at 58° C. 
In Japan this was first tried, using two milligrams of 
culture. Of those inoculated, 0.06% acquired the disease 
and 0.02% died, as compared with 0.13% of cases and 
0.1% deaths in those not inoculated. After the dose of 
vaccine was doubled, not another case occurred among 
those inoculated. 
Modes of Transmission.—Water has been the medium 
through which the great epidemics have been propagated. 
This was particularly well shown by Koch in 1892-93, 
during the epidemic at Hamburg, when he was able to 
recover the bacilli from the city water supply repeatedly. 
In strictly localized outbreaks the same mode of trans- 
mission often operates. Milk is occasionally responsible 
for a few cases, but is not of great significance. Vege- 
tables fertilized with sewage, as is the custom in many 
countries, have been known to produce small outbreaks. 
Contact is probably the chief mode of transmission, 
after water. It is believed that it plays a large part in the 
continued presence of the disease in India. Dirty hands 
and freshly soiled clothing are the immediate instruments 
of transference. 
Undoubtedly flies are responsible for many cases, as is 
true of typhoid fever, by carrying cholera laden excreta on 
their feet and in their intestinal tracts. 
Carriers of two classes have been recognized, active and 
passive, or convalescent and contact. Fortunately the 
organisms do not persist in the stools of either for as long a 202 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
period as in the case of typhoid carriers. In fact, most of 
them lose their vibrios within two or three weeks. The 
interesting point to note in connection with cholera carriers 
is the fact that persons in contact with cases may develop 
the carrier state without showing any symptoms of disease. 
The carrier is important as a source of new outbreaks, or in 
keeping alive one that has already started. 
Diagnosis.'—Diagnosis is chiefly of academic interest in 
this country, at present, but, like plague, may assume a more 
practical aspect at any time, especially in our port cities. 
Clinical symptoms of cholera may range all the way from 
a simple diarrhea to the most sudden and profound pros- 
tration, with fever, violent diarrhea and rapidly ensuing 
death. A distinction should be made between true cholera 
and the disease of infants known as cholera morbus, nostras 
or infantum. The latter is probably more akin to 
dysentery. 
Laboratory diagnosis is comparatively certain and is 
always depended upon by the Immigration Inspectors for 
the detection of cases or carriers. Its successful applica- 
tion is witnessed by their record, already referred to. 
Methods of Control.—Control of the patient includes 
concurrent disinfection of his stools, urine and articles 
that have been in contact with him. The attendants must 
exercise scrupulous cleanliness of the hands. 
In water borne outbreaks the supply must be chlorinated 
until all pollution has been removed. Sewage should be 
treated in order to place as little burden as possible upon 
the water purification apparatus. 
Excreta disposal must be safeguarded by the usual 
means, including the screening of privies and the prohibi- 
tion of promiscuous scattering of feces upon the ground. 
Carriers must be sought for in all outbreaks, especial 
attention being given to those who have been in contact 203 
ACUTE CONTAGIOUS CONJUNCTIVITIS 
with cases. At times it is necessary to establish emergency 
laboratories and to carry on extensive surveys of the 
population for this purpose. 
Border quarantine is an exceedingly important feature 
of cholera control. By its unceasing vigilance and strict 
enforcement alone can a country be kept free of the disease, 
for little has been done among the more backward nations 
to control its spread. In addition to these measures, our 
government maintains inspectors at the southern European 
ports of departure, for the purpose of detaining suspects 
and of notifying this government of disease prevalence. 
Mortality.—Sixty per cent., or more, of cholera cases 
prove fatal. It is the cause of thousands of deaths in 
India every year. During the great war the disease spread 
into the Balkan states and even reached portions of 
western Europe, causing much destruction of life. Our 
own nation has paid its toll to the disease in times past 
and is free today only through the untiring watchfulness 
of our outposts. 
5. ACUTE CONTAGIOUS CONJUNCTIVITIS 
Under this heading fall a number of communicable eye 
infections aside from trachoma. The most important of 
these are gonorrheal ophthalmia and the condition commonly 
known as “pink eye.” This latter infection, however, is 
entirely overshadowed by the former which is responsible 
for more conjunctivitis and resulting blindness than any 
other single eye disease. “Pink eye” rarely produces any 
permanent effects. Its exciting organism is the Koch- 
Weeks bacillus and it is extremely contagious, being spread 
in the same manner as trachoma. Control of an outbreak 
is secured by preventing the transference of eye secretions. 
The following discussion will deal entirely with the 
gonorrheal form of ophthalmia. 204 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Infective Agent.—The gonococcus is the exciting cause, 
sometimes accompanied by other pyogenic bacteria. 
Incubation Period.—Only two or three days elapse, 
after infection, until symptoms make their appearance. 
Immunity.—So far as we know, all persons are susceptible 
to the infection, new-born infants in particular. 
Modes of Infection.—In the case of the majority 
acquire infection during birth, from the infected genital 
tract of the mother. They may also be infected, subsequent 
to birth, by the contaminated fingers of the mother or 
nurse. 
A person suffering with an ordinary gonorrheal urethritis 
may transfer infection to his own eyes, or to those of 
another, by means of his contaminated fingers, or by a 
common towel. 
Diagnosis.—Microscopic examination of the pus from 
an inflamed eye reveals the characteristic intracellular 
diplococcus, which is negative to Gram’s stain. 
In the absence of microscopic evidence, an eye presenting 
the following symptoms, together with a history of likeli- 
hood of a gonorrheal infection being present in patient or 
associates, would warrant a clinical diagnosis of gonorrheal 
ophthalmia; intense redness, profuse discharge of pus, 
extreme photophobia, tenderness and swelling of the eyelids 
and adjacent parts. 
Methods of Control.—All that is said under “ Trachoma,” 
as to preventing the transference of eye discharges, applies 
with particular force to this disease. In the case of the 
new born, infection can be practically eliminated by the 
simple procedure of dropping a one or two per cent, solution 
of silver nitrate into the eyes, immediately after birth. 
Many states make this compulsory for all births, but the 
vast amount of blindness still prevalent, from this cause 
alone, indicates the urgent need of universal regulation, DENGUE 
205 
together with education of the public. The question is 
further bound up with the entire subject of venereal disease 
control, which will be discussed in a separate chapter. 
Mortality.—There is no mortality from the disease, but the 
ensuing blindness is often worse than death itself. At least 
one-fourth of all blind in the world are the victims of gonor- 
rheal infection, usually acquired from the mother at birth. 
6. DENGUE 
While dengue is principally a disease of tropical and sub- 
tropical climates, it has been found as far north as Charles- 
ton and is frequently encountered in Texas. It tends to 
appear in extensive epidemics that spread rapidly and 
affect a greater portion of the population than even influ- 
enza. The disease has been popularly called “break bone 
fever” or “dandy fever,” due to the pain and stiffened 
gait of the sufferer. 
Infective Agent.—The specific cause of dengue has not 
been discovered, but it has been demonstrated to be a 
filterable virus, present in the blood plasma of patients 
and inoculable into healthy persons by injecting the blood 
of those suffering with the infection. 
Incubation Period.—Incubation of experimental cases 
covers from 3 to 14 days. The average, so far as it can 
be determined for naturally acquired cases, is given as 
1 to 3 days. 
Immunity.—There appears to be no natural immunity 
to dengue, but protection may be acquired by an attack 
of the disease and will persist for at least a year. 
Modes of Transmission.—It seems to be fairly well 
established that the infection is transferred by the mosquito 
Culex fatigans. One author in Australia also implicates 
Aedes calopus. At least, we know that the affection 
is not contagious in the ordinary sense. 206 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Diagnosis.—Manson gives the following summary of 
cardinal symptoms: “. . . the essential symptoms in well 
marked cases are the same practically everywhere, and in 
all epidemics; these are, suddenness of the rise of tem- 
perature, an initial stage of skin congestion, limb and joint 
pains, and a terminal rubeoloid eruption.” 
The attack is usually ushered in without warning by a 
rapidly rising temperature and the development of excru- 
ciating pains in the head, joints and muscles. Exhaustion 
is extreme, due to pain and high temperature. After 
three days, these symptoms may entirely disappear and 
the patient be able to go about his business. However, 
after three or four days, a second attack supervenes and 
the early history is repeated. At this time the rash 
develops, but is not characteristic in its form. Symp- 
toms gradually subside, but traces may be left for a long 
time. Ordinarily the entire attack covers a period of 
about ten days. Nervous depression may persist for 
months, after all acute symptoms have passed. 
The principal features mentioned above, coupled with 
a widespread epidemic of the same character, would serve 
to differentiate the disease from any other. 
Methods of Control.—Measures to control dengue 
should be directed against the mosquito, culex fatigans, 
which is quite ubiquitous and is given to biting at almost 
any time of day. Practically the same methods should 
be used as are applicable to .eradication of the malaria 
mosquito. 
Screening will protect the well and also prevent mosqui- 
toes from reaching the sick. No measures, other than 
screening, are required in controlling the patient. Mosqui- 
toes in the sick room should be destroyed. 
Mortality.—Only rarely does a person suffering with 
dengue succumb, so we may say that the mortality is nil. DIPHTHERIA 
207 
The disease is important because of the rapidity of its 
spread and the prostration of a large portion of the popula- 
tion at one time. 
7. DIPHTHERIA 
From the time of Homer to the present, diphtheria has 
held a leading place among all causes of death and first 
rank among the acute, infectious diseases. Unlike many 
of the others, it kills, not so much by its complications, 
but by itself, through the generalized toxemia produced. 
Prior to the discovery of antitoxin, by Behring, the percent- 
age of deaths amounted to about 75, but the case fatality 
rate has been reversed, since antitoxin came into wide- 
spread use, and even more can be expected following the 
introduction of adequate public health administration, with 
its modern methods of control and better provisions for 
early treatment. 
Infective Agent.'—Klebs first suggested that a peculiar 
bacillus might be responsible for the manifestations 
of diphtheria and, a year later, LoefRer satisfactorily 
demonstrated that this organism was really the infective 
agent. It now bears the name Bacillus diphtheriae, or 
Klebs-Loeffler bacillus. For a detailed description of the 
organism, the reader is referred to recent works upon bacteri- 
ology. It should be noted here that the habitat of the 
bacillus, when found within the human body, is principally 
in the tonsilar crypts and in the protected structures of 
the nose. 
Incubation Period.—Incubation is quite brief, lasting 
not over seven days, as a rule, and usually terminating 
in two. It is sometimes difficult to determine with exact- 
ness, for the reason that a person may harbor the bacillus 
in his throat for a considerable time without presenting 
any symptoms of disease. 208 
ELEMENTS OF PUBLIC HEALTH ADIMINSTRATION 
Immunity.—Natural antitoxic immunity appears to 
exist, to some extent, and to be quite variable, dependent 
upon certain factors which we do not understand as yet. 
Children from the age of six months to ten years are most 
susceptible. Recent work tends to show that crowding, 
with resultant repeated exposures, confers greater immunity 
than that found among children who are not allowed to 
run the streets. In most cases an attack of the disease will 
confer an active immunity varying from months to years. 
This can also be produced by injections of a toxin-antitoxin 
mixture. 
The latter has been giving such satisfactory results in 
the hands of Park and others that it may be recommended 
as a routine. Observations by the authors, extending 
over a period of two years, have indicated that the prepa- 
ration is safe and satisfactory, when produced by reliable 
laboratories. Park has been able to demonstrate cir- 
culating antitoxin in the blood of children immunized six 
years ago. The usual procedure in applying toxin-anti- 
toxin is, first, to eliminate all immune persons by means of 
a Schick test survey and, then, to control the results of 
immunization by further Schick tests on those formerly 
susceptible. At least 85% of these latter can be immunized 
by three 1 c.c. doses of the mixture, given at about weekly 
intervals. A rather long period of time is required to 
develop the full immunizing effect, extending at times to 
three months from the last dose. A prophylactic dose of 
antitoxin, given just prior to, or during, the administration 
of toxin-antitoxin, will diminish the effect of the latter to 
some extent. This can be overcome by increasing the 
number of doses. 
Passive immunity is produced by ther use of horse blood- 
serum from actively immunized animals. Such a prepara- 
tion is an “ antitoxin” and its nature should be well DIPHTHERIA 
209 
understood in order to appreciate its proper uses and limita- 
tions. There is introduced into the circulation of the horse 
a definite amount of toxine,1 to which most of the symptoms 
are due. This toxine is a mixture of complex chemical 
compounds and may be found in many parts of the body 
not invaded by the bacillus at all. Its effect is promptly 
to arouse certain forces of the body which compound 
corresponding substances that neutralize the toxine. These 
substances are the “antitoxin” which we apply for pro- 
phylactic and therapeutic purposes. A given quantity 
of it will destroy a like amount of toxine and the two can 
be measured with remarkable exactness, so that we are able 
to provide various doses of antitoxin containing “units” 
in definite quantities. From a given number of units we 
can expect a certain amount of protective or curative 
effect, and no more. One point that should be understood 
is that the antitoxin has no effect, upon the bacillus itself; 
it simply neutralizes the toxine produced by the bacillus. 
Another interesting feature of antitoxin from the horse is 
that the human body eliminates most of it in two or 
three days and all of it in two to three weeks. Also, the 
higher the number of units introduced, the longer will be 
the period of effective immunity. This is one of the 
strongest arguments for large doses, given early, in treating 
a case of diphtheria. 
The Schick Test is a valuable method of determining the 
presence of natural or acquired immunity to diphtheria. 
The test is performed by injecting between the skin layers 
hio of one cubic centimeter of a standard dilution of diph- 
theria toxin. If no immunity is present, a distinct red 
areola appears in about 24 hours at the point of inoculation; 
1 Note that the word ‘‘toxine” is used, as suggested by Rosenau, to mean 
the entire filtrate from a culture of B. diphtheriae and contains toxin, toxon 
and other substances. 210 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
this turns to a brownish area, which gradually fades. If 
immunity is present, no reaction appears. There is, 
however, an occasional pseudo-reaction which may cause 
some difficulty in differentiation. Directions for applying 
the Schick Test will be found in the appendix. 
Modes of Transmission.—Droplet infection and ordinary 
contact are principally responsible for the spread of the 
disease. The bacteria have been demonstrated upon articles 
recently soiled with the saliva of patients and carriers, 
so that these objects may also contribute to its dissemina- 
tion. It can readily be seen that a carrier or patient could 
also impart the infection to susceptible children by kissing. 
In diphtheria the carrier problem is one of tremendous 
importance. Careful studies conducted in various parts 
of the world indicate that carriers form about one per cent 
of the entire population. 
This is probably the explanation for those sudden and 
otherwise unexplained epidemics that appear in various 
communities with great frequency, and is also the reason 
for persistent recurrences of cases in a neighborhood. 
Carriers are divided into two classes, active and passive. 
The former are those who are convalescing from an attack 
of the disease, while the latter are those who have been 
in contact with a patient, or with another carrier, but 
have exhibited no symptoms of infection. In about half 
of the cases of active disease all bacilli disappear from the 
nose and throat in two weeks. Among the remainder the 
time varies widely and the condition occasionally becomes 
chronic. In one reported case the carrier retained virulent 
organisms after eight years of observation. The passive 
carrier sometimes falls victim to his own germs, developing 
an active case after having harbored the bacilli without 
symptoms, perhaps for months. Several cases of this sort 
have come under our personal observation. DIPHTHERIA 
211 
Diagnosis.—With laboratory facilities available, diag- 
nosis of a case should rest entirely upon the bacteriological 
findings. The procedure is so simple and the results so 
certain, that this safeguard to the patient should never be 
ignored in any suspicious throat lesion. Lacking such 
opportunity for positive diagnosis, the disease must be 
differentiated from septic sore throat, and, sometimes, 
from scarlet fever. Occasionally other conditions present 
a pseudomembrane, but the two mentioned are the ones 
in which it is commonly encountered. Tonsilitis should 
offer no difficulties to anyone who has seen the diphtheritic 
membrane. In distinguishing the other two diseases 
named from diphtheria, the outstanding feature of the 
latter affection is that the patient is not so sick, at first, as he 
usually is with either of the other infections. They both 
present sudden and profound prostration whenever their 
severity is sufficient to give rise to a pronounced membrane 
formation. It frequently surprises the practitioner to find 
a child up and playing about, with a well developed 
diphtheritic membrane in its throat and a moderate fever. 
When in doubt, play safe and treat it as diphtheria. 
No harm is done and a life may be saved that would other- 
wise be sacrificed. 
Diagnosis of a carrier condition rests entirely with the 
laboratory. No reliance whatever should be placed upon 
the appearance of the throat, for a very large proportion 
of such persons show no evidence whatever of any inflamma- 
tory process in either throat or nose. This is particularly 
true of temporary carriers; while some who develop a 
chronic condition of this sort may have inflamed tonsils, 
an atrophic rhinitis, or a discharging sinus. In dealing 
with carriers it is important to determine whether the 
organisms present are virulent, or not. Many virulent 
types are encountered that can be distinguished from the 212 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
dangerous forms only by animal innoculation. When 
the carrier condition persists, it is necessary to have a 
virulence test made in order to determine whether the 
carrier should be kept under continued surveillance. 
It is quite important to observe correct technique in 
taking cultures. Two perfectly sterile swabs must be 
used, one for the nose and the other for the throat, in order 
to determine the exact location of the bacteria. The throat 
swab is passed back to the tonsils, without touching the 
tongue, in order to avoid contamination with mouth 
bacteria, and is pressed deeply into the membrane, or into 
the crypts of the tonsil, if no membrane is present. It 
should be slightly rotated in order to gather as much infec- 
tive material as possible. The nose swab is gently inserted 
well into the posterior nares and rotated. Both swabs are 
replaced in their respective sterile containers, without 
being allowed to come into contact with anything else 
whatever. Each container should be marked so that 
cultures from the two locations may be distinguished. If 
culture medium is used, the swabs are gently rubbed upon 
the surface of the medium and then destroyed by burning. 
The customs of state and city laboratories vary, some 
supplying only the sterile swabs, while others furnish 
culture medium. 
It should be borne in mind that, in the case of carriers, 
only a comparatively few bacilli are present, as a rule, 
upon the surface of the mucuous membrane, except after 
recent contact with a case. Consequently, a single 
examination may not reveal them at all. If, however, a 
person has once been found to harbor the organisms, he 
should not be regarded as free of them until repeated 
swabbings of the deep tonsilar crypts and the recesses of 
the nose show no diphtheria bacilli present at any time. 
Many health departments require three successive negative DIPHTHERIA 
213 
cultures, taken 24 hours apart, before releasing a carrier 
or a case. 
Methods of Control.—The subject of control is broadly 
divided into the control of the case and the control of the 
carrier. 
The patient sick with diphtheria must be isolated and all 
discharges from his nose and throat destroyed. Articles 
soiled with these discharges must be thoroughly disinfected, 
if they cannot be burned. Particular attention should be 
paid to cases of diphtheria in connection with dairies, to see 
that the nurse has no contact whatever with the handling 
of milk intended for public distribution. When clinical 
symptoms have subsided, but bacteria are still present in 
the throat, the patient becomes an active carrier and will 
be considered under that head. 
Such a mass of detailed information has accumulated 
with reference to the management of the carrier that only 
an outline of the essential points can be attempted here. 
Simon’s Human Infection Carriers gives a concise dis- 
cussion of our latest knowledge on this subject and is worthy 
of close study. As was said a moment ago, the patient 
becomes an active carrier when free of symptoms. From 
that time on, his condition can be determined only by 
cultural tests. It should be noted here that the attending 
'physician's function is completed, when his patient is 
clinically cured, and that from that point on the manage- 
ment of the person who has been ill is the health officer's 
responsibility as a guardian of the public health. This is a 
distinction that is seldom made and thereby breeds much 
discord between physician and health officer, or else, tends 
to slakening of public health control. The attending 
physician has no further rights in the case whatever, when 
it becomes solely a question of controlling the individual 
for the good of the public and not for his own good. The 214 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
health officer, then, must determine the length of isolation, 
and his sole means of reaching a decision is the laboratory 
report. No person who has had an attack of diphtheria 
should be released until three successive negative cultures 
have been secured. These cultures should be taken not 
less than twenty-four hours apart and it is important to 
know that the subject has not used any antiseptic in the 
throat for at least twelve hours prior to swabbing. When 
one encounters a persistent carrier, it eventually becomes 
necessary to arrange for his release; but this should be pro- 
visional and under the constant supervision of the health 
officer. It must be borne in mind that not all diphtheria 
bacilli found in the naso-pharynx are virulent. Therefore, 
the health officer should have virulence tests made in the 
case of persistent carriers, in order to relieve those who are 
inocuous from further supervision. 
Those persons who have been in immediate contact with 
the patient are the next important concern, for, after the 
patient, they are potentially the most dangerous. The 
health officer should take cultures from all such, imme- 
diately upon discovery of a case, isolating those found to be 
carriers, just as he would isolate a patient sick with the 
disease. Such carriers should be given a prophylactic 
dose of antitoxin, for a certain number of them will develop 
symptoms, if unprotected. All contacts who do not show 
bacilli should likewise be immunized, or, refusing that, 
quarantined for five days. A showing of positive immunity 
by the Schick test would at once release a person from the 
quarantine mentioned, provided that he harbored no 
virulent bacilli. Application of the test also conserves 
antitoxin by pointing out those who carry their own natural 
supply. 
The secondary passive carrier, who has had no contact 
with an active case or active carrier, so far as ordinary DIPHTHERIA 
215 
investigations will show, offers a problem of some difficulty 
to the health officer. For, while we know that he is 
present to a certain extent, he cannot be singled out by 
any method except cultural examination of large groups. 
However, when diphtheria becomes prevalent among school 
children, or any other closely associated body of persons, 
no alternative is left but to examine every throat and nose 
culturally. Carriers discovered are managed as described 
above. In such a survey, one of the authors found 50 
carriers in a school of 500, during a small outbreak of 
diphtheria. Some of these carriers later developed the 
disease. 
Treatment of the carrier, in order to rid him of his 
“fatal gift,” frequently falls to the lot of the health officer, 
or comes under his supervision. The list of remedies 
used for this purpose resembles a small abstract of the 
pharmacopeia, testifying thereby to their general failure 
to produce the desired result. From what was said earlier, 
it is apparent that antitoxin is not of any avail in clearing up 
passive carriers, even when applied directly to the throat 
and nose. However, encouragement is derived from the 
fact that the majority of carriers gradually throw off the 
organisms without aid, in the course of a few weeks. There 
remain, then, a small class that must be somehow dealt 
with. For them surgery offers the quickest means of cure. 
Since the bacilli lie hidden in the crypts of the tonsils 
and in the deeper structures of the nose, these are the 
obvious points of attack. It will be found that most 
persistent carriers have enlarged, and sometimes diseased, 
tonsils. Their removal produces a cure quite often and 
usually within thirty days following operation. Removal 
of nasal obstructions, including adenoids, also has a favorable 
effect in some cases. One chronic carrier coming under our 
observation was a boy who had a small cork lodged in his 216 
ELEMENTS OF PUBLIC HEALTH ADMINISTKATION 
nose, and which had been there probably for years. Four 
days after the cork was removed, the bacilli disappeared, 
although he had been a carrier for four weeks at least. 
Finally, we reach an irreducible minimum which cannot be 
freed of virulent bacilli. These unfortunate persons must 
be held in isolation long enough to impress upon them the 
danger to others from their condition, and allowed to 
go only under the constant surveillance of the health 
officer. If an outbreak can be traced to one of them, he is 
thereby convicted of criminal negligence and must again be 
isolated. 
The practice has grown up in a few places of making 
Schick test surveys of large groups of children and 
immunizing the susceptibles with a toxin-antitoxin mix- 
ture. Where reliable preparations of toxin for these tests 
are available this offers the most satisfactory method of 
protecting this most susceptible portion of the population. 
However the practice is growing of giving toxin-antitoxin 
without Schick testing, where it is not practicable to make 
the test. In view of the volume of evidence in support of 
this prophylactic, such procedure is amply justified and has 
a pronounced effect in reducing the diphtheria rate, 
where it is extensively employed. 
In the face of a scattering outbreak of diphtheria, the 
health officer should make a cultural examination of all 
persons connected with the handling and sale of milk, if 
suspicion attaches to this product as a possible medium of 
transmission. If evidence points strongly to a milk supply 
and no carriers can be found at once, pasteurization should 
be immediately demanded as a temporary measure until 
further search for a carrier can be made. 
Mortality.—In 1917 the death rate for diphtheria in the 
Registration Area of the United States was 16.5 per 100,000. 
Since then it has not materially decreased. And yet, only a DYSENTERY 
217 
fraction of one per cent, of cases die, if treated promptly 
with antitoxin. The appalling mortality has three explana- 
tions: failure on the part of the physician to diagnose 
properly; failure to administer antitoxin either sufficiently 
early or in large enough quantity, and failure of the public 
to appreciate the necessity of calling a physician in every 
case of sore throat. With a suspicious membrane in the 
throat, valuable time should not be lost by waiting for a 
report upon a culture, if it cannot be had within twelve to 
twenty-four hours, depending upon the severity of the case. 
IT IS AXIOMATIC THAT EARLY ADMINIS- 
TRATION OF A LARGE DOSE OF ANTITOXIN 
WILL SAVE PRACTICALLY EVERY CASE OF 
DIPHTHERIA. By ‘ ‘ early administration ” is meant with- 
in the first twenty-four hours. By a 11 large dose” is meant 
10,000, or more, units. Except in the youngest infants, 
the physician should not fail to give a dose of this size at 
once. Given then, it will do infinitely more good than if 
divided into two or more smaller doses administered over a 
period of a day or two. IT MAY MEAN THE DIFFER- 
ENCE BETWEEN LIFE AND DEATH FOR THE 
PATIENT. In extreme cases, give the antitoxin intra- 
venously, after one cubic centimeter has been injected 
subcutaneously to test the individual’s sensitiveness. We 
cannot expect a further fall in the death rate for diphtheria, 
until physicians universally adopt these practices, together 
with the active immunization of all who will accept it. 
The term dysentery can no longer be considered as having 
specific significance, but is rather a group designation for a 
number of infections presenting identical symptoms. Two 
large divisions, or types, are recognized, bacillary and 
amoebic, but even these cannot be distinguished clinically. 
8. DYSENTERY 218 
ELEMENTS OF PUBLIC HEALTH ADMINISTEATION 
Both diseases are, however, infectious, appearing in exten- 
sive epidemics at times, so that they may assume consider- 
able sanitary importance. Dysentery formerly was a plague 
to armies more disabling than the enemy’s fire. Extensive 
outbreaks of this sort have disappeared, but circumscribed 
groups of cases were frequently seen even in the late war. 
Infective Agent.—In the bacillary group are found several 
well defined strains of bacilli, each producing typical 
dysentery. The more common of these are the Shiga and 
Flexner varieties. Besides, there are some bacilli that are 
found only occasionally, while in other cases of clinical 
dysentery organisms have been found predominating in the 
stools that could not be indisputably connected with the 
disease as causal agent. It is not necessary to go further 
into the bacteriology of the group for the purposes of this 
discussion. 
Amoebic dysentery is produced by a protozoan unicellu- 
lar organism known as entamoeba histolytica, and occa- 
sionally by lamblia intestinalis. 
Incubation Periods.—It is impossible to give definite 
incubation periods, but the time is thought to be quite short. 
Immunity.'—So far as known no natural immunity exists 
to any of these types of infection. Antisera for the 
bacillary type have given quite promising results when 
used therapeutically. There is nothing of the sort, however, 
for the amoebic form. In the latter condition ipecac would 
probably maintain a certain degree of immunity as long 
as administered. 
Modes of Transmission.—In the United States the usual 
vector of bacillary dysentery is probably the fly, while 
extensive outbreaks are occasionally seen as the result of 
water pollution. However, dysentery is commonly the 
result of unprotected human filth, lying on the open ground 
or in unscreened privies, exposed to the approach of the DYSENTERY 
219 
ubiquitous fly. Connection must be quite direct between 
the excreta of patient or carrier and the mouth of another 
person. 
Amoebic dysentery is not indigenous to this climate, 
but is usually an importation from the tropics. It is occa- 
sionally found in endemic foci in the southern part of the 
United States. The infective form of the amoeba is the 
cyst, which is carried by water and may also be blown about 
in dust contaminated with it. 
Diagnosis.—There are two outstanding clinical features 
of dysentery, severe diarrhea and mucus in the stools. 
The bacillary type also produces considerable toxemia, in 
the majority of cases, while the amoebic type is more 
chronic and lacking in the latter feature. It does, however, 
tend to the formation of hepatic abscesses. Amoebic 
dysentery can often be differentiated from the bacillary 
type by the administration of ipecac. This drug is specific 
for amoebae, but has no effect on the bacilli. 
Laboratory examination of a patient’s stools will usually 
reveal the diagnosis, if done by a competent bacteriologist. 
Identification of the dysentery bacillus, however, is tedious 
and recognition of the entamoeba histolytica requires 
acquaintance with all forms of amoebae that may be found 
in the intestines. 
Methods of Control.—The principal control measure for 
dysentery is that directed at the proper management of 
the patient. Concurrent disinfection of the stools and of 
all articles soiled with them, screening against flies, and 
care of the attendant’s hands, are essential. 
Water borne outbreaks are controlled by chlorination of 
the water supply and proper safeguarding of its source. 
Convalescents must be watched to insure safe excreta 
disposal, until the stools have returned to normal. This 
demands that privies, if used by such persons, shall be 220 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
absolutely fly-tight and the contents disposed of in a 
sanitary manner, by either burying, burning or dumping 
into a sewer that is properly supervised. 
The health officer should receive reports of all dysentery 
cases and see that these measures are strictly applied. 
He should be especially careful that a convalescent is not 
engaged in the handling of food for public consumption. 
Mortality.—Some forms of bacillary dysentery are fatal 
in as high as 35% of cases. Other forms do not produce 
such great mortality. 
Untreated amoebic dysentery has about 25% mortality, 
but the early use of ipecac reduces this to practically 
nothing. In the southern United States it would be well 
to suspect this type of infection in all cases of the disease 
and to administer some form of the drug upon the first 
appearance of symptoms, unless profound toxemia is 
present. Two or three days will suffice to produce some 
improvement, if amoebae are the infective agent. While 
this plan is not ideal, it may save many cases that would 
otherwise result in chronic invalidism or death. Since the 
stools must be examined in a fresh state, if amoebae are to 
be detected, it is impossible to send specimens to a distant 
laboratory for examination. 
9. FAVUS 
Favus is a parasitic skin disease which sometimes gains a 
foothold in a school and is rather resistent to treatment. 
It attacks the scalp in practically all cases. 
Infective Agent.—The specific agent producing the disease 
is a vegetable fungus, the Achorion schonleinii, which grows 
in the hair, the hair follicle and in the epidermis surrounding 
the latter. The fungus throws out fine, hairlike branches 
which form a thick, bright yellow mat about the root of 
the hair. FAVUS 
221 
Incubation Period.—The incubation period is unknown. 
Immunity.—While Russians, Poles and Italians of the 
poorest class most commonly present the disease in this 
country, it is often seen in native Americans. 
Modes of Transmission.—Crowding and lack of hygiene 
favor the spread of favus. Wearing a hat of an infected 
individual, or sleeping in the same bed with him, or using 
a brush and comb that he has used, are the commonest 
means of spreading the disease. Domestic animals are 
said to suffer with the infection and to be capable of 
transmitting it to human beings. 
Diagnosis.—About the affected hairs are sulphur-yellow 
crusts, that have a cup-shaped appearance which is regarded 
as characteristic. This crust is formed by masses of fungus 
growth and is quite dry and friable. The hairs gradually 
fall out, in the regions of infection, leaving irregular bald 
patches. 
Ring-worm of the scalp is to be distinguished from favus 
by its more rapid course and the tendency to form well 
defined round areas, with the hairs broken off in such a 
manner as to give a “gnawed off” appearance. The color 
of the ring-worm lesion is more of a reddish brown. The 
microscope will distinguish favus from purulent infections 
which may resemble it. 
Methods of Control.—Personal cleanliness will usually 
protect against infection. 
A child with the disease should be excluded from school 
until cured. Cloak rooms in school buildings should be 
provided with hooks sufficient for all pupils and each one 
should be compelled to use the hook assigned, at all times. 
Exchange of hats should be discouraged. Free clinics for 
the treatment of such cases are needed, for the same reasons 
mentioned under impetigo and trachoma. 
Mortality.—There is no mortality from favus. 222 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
10. FILARIASIS 
There are at least half a dozen filariae that are parasitic 
in the human body. Only one is of any particular signifi- 
cance, however, and the discussion will be confined to it, 
viz., filaria bancrofti. 
These forms are found chiefly in the tropics, but occa- 
sionally in other latitudes, even in the United States. Such 
cases, however, are usually imported from the tropics. 
Infective Agent.—The filaria is a nematode that is 
parasitic in man and mosquitoes. Adult forms are not 
found in the blood, but in the deep lymphatic vessels, 
where they lie in pairs and reproduce at frequent intervals. 
The female is a slender thread, about 80 mm. long, while 
the male is even more slender and only about half the 
length. 
The larvae are slender, transparent worms, about 0.3 mm. 
in length. They are actively motile and are enclosed in a 
delicate membrane, within which they constantly move 
about. A striking feature of this particular species of 
parasite is that it makes its appearance in the peripheral 
circulation only when the human host is asleep. It is 
present in greatest numbers about midnight and has 
disappeared by morning. This periodicity is quite regular. 
The larvae may be present in enormous numbers in the 
circulation without causing any apparent symptoms. 
Manson has demonstrated that they retire to the larger and 
deeper vessels during their absence from the peripheral 
blood stream. 
Incubation Period.—The period required for a pair of 
larvae, introduced into the body, to reach sexual maturity 
and produce new generations, is unknown. 
Immunity.—No natural immunity to the parasite has 
been demonstrated. GERMAN MEASLES 
223 
Modes of Transmission.—Mosquitoes are the vectors of 
the worm. When a mosquito bites a person whose blood 
is infested with the parasites, a few of the larvae are taken 
into the insect’s stomach with the aspirated blood. Here 
the delicate enveloping membrane of the larva is shed and 
the worm emerges as an actively motile organism. It 
penetrates the stomach wall and works its way among the 
muscle fibres to the mosquito’s head, where it travels down 
the proboscis, always with a mate, to lie in wait for an 
opportune time to enter a new human host. This is 
accomplished by piercing the outer covering of the probos- 
cis at the time that the mosquito bites. 
Some observers believe that the parasite may leave the 
mosquito’s body at the time she lays her eggs and can then 
be acquired by persons drinking such infested water. No 
proof of this has been offered, however. 
Diagnosis.—Diagnosis is made by microscopic examina- 
tion of a fresh drop of blood, taken at night, or by stained 
smears. 
Methods of Control.—Control of the mosquito and 
screening of infested individuals are the methods of pre- 
venting parasite transference. 
Mortality.—Death from filariasis results only occa- 
sionally, due to inflammation set up by the parasite in the 
lymphatics. 
It is believed, however, that the condition known as 
tropical elephantiasis is a direct result of lymphatic obstruc- 
tion caused by the filaria. This disease is disfiguring and 
distressing in the extreme and may cause death through 
inflammation or gangrene of the affected parts. 
11. GERMAN MEASLES 
German measles is of significance to the health officer 
principally as an affection to be distinguished from other 224 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
diseases. Its mortality is practically nil and it has no 
important sequelae. 
Infective Agent.—Nothing is known of the organism 
producing it, but some form of living organism is assumed 
from its general conformity to other conditions caused by 
microorganisms. 
Incubation Period.—The incubation period is quite 
variable, according to many observers, ranging from five 
to twenty days, with an average of fourteen. Further 
investigations may show these limits to be excessive. 
Immunity.—So far as known, all persons are susceptible. 
One attack appears to confer immunity for life. 
Modes of Transmission.—Droplet infection is probably 
the principal means of transference, but this has not been 
demonstrated, as yet. The hands and articles soiled with 
the fresh secretions may contribute to its spread. 
Diagnosis.—For many years, German measles was 
regarded as a hybrid measles, or hybrid scarlet fever, for it 
partakes somewhat of the symptoms of both diseases. It 
is to be distinguished from measles by the usual lack of any 
prodromal symptoms, by lower temperature, by the absence 
of Koplik’s spots in the mouth and mild or absent catarrhal 
symptoms, as well as by the character of the eruption. 
The rash is commonly the first symptom noticed. From 
scarlet fever it may be differentiated by the early sub- 
sidence of the rash and by the absence of both the “straw- 
berry tounge” and severe tonsilar involvement. The 
throat, however, presents more inflamation than in measles. 
A sign of considerable dependability is the enlargement 
of the occipital lymphatic glands, which often assume 
great size. The eruption is of a rose tint, lacking the 
brightness of scarlet fever and the somewhat bluish cast 
of measles. However, the diagnosis of an isolated case 
is often exceedingly difficult, in the early stages. It is HOOKWORM DISEASE 
225 
wise to make a guarded diagnosis and to establish tentative 
isolation. 
Methods of Control.—Exclusion of the patient, for seven 
days, from school, from public gatherings and from contact 
with non-immunes, is sufficient, together with concurrent 
disinfection of nose and throat discharges. 
Non-immune contacts should be held in modified quaran- 
tine of the same character, for twenty one days, if at all. 
School children, exposed to a case, should be inspected 
daily for suspicious symptoms, until the incubation period 
is passed. This inspection need not start until the fifth 
day after the first exposure. 
Mortality.—The mortality of German measles is neg- 
ligible. 
12. HOOKWORM DISEASE 
After malaria, hookworm infestation has been the most 
prolific cause of disability and economic deterioration in 
our Southern States. Many counties have shown an 
incidence as high as 90% of the population. The parasite 
has been found in various parts of the world, and is fre- 
quently the cause of defective development and marked 
inefficiency throughout large areas of the tropics. 
Infective Agent.—Many varieties of hookworm have 
been described, each being parasitic for only one or 
two animal hosts. Man is favored by two species, the Old 
World hookworm, Ankylostoma duodenale, and the 
American variety, Necator americanus. 
Only the adult worm is parasitic in man. It fastens 
itself to the intestinal mucosa by means of a hooklet and 
sucker. The membrane is pierced and blood withdrawn 
by the worm, a part being ingested as food and the rest 
wasted. The female continuously discharges eggs, which 226 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
are thrown off with each bowel movement of the host and 
commence their life cycle, if conditions are favorable. 
Warmth and moisture are essential to hatching, hence 
the worm flourishes more abundantly in warm, humid 
climates. Dryness and freezing are fatal to the larvae 
within 24 hours. 
A day is required for the larva to hatch from the egg. In a 
few days it sheds its skin, and again a few days later. The 
second moult is not thrown off, but forms a protective coat. 
In this state the larva has slight motility and is able to 
penetrate the skin. 
Incubation Period.—Experiment has shown that from 
7 to 10 weeks elapse from the entry of the larva through 
the skin until eggs are to , be found in the stools of the 
host. 
Immunity.—No immunity to hookworm infection is 
known to exist. 
Modes of Transmission.—In a very small percentage of 
cases infestation may be acquired from water, vegetables, 
or by mouth from hands that are contaminated with the 
larvae. The latter can survive in water of proper tempera- 
ture for about a month. 
The great bulk of infestation is received from polluted 
soil. In this medium the encysted larva can continue its 
existence for several months. The common point of entry 
for the larva is through the skin of the feet, especially 
between the toes. As it penetrates the skin an irritation 
is set up which is widely known as “ground itch.” It may 
also enter through the skin of the hands or arms, in case 
polluted soil is handled. 
Once having invaded the deeper tissues, the larva travels 
by way of the lymphatics to the vena cava, and finds 
lodgement in the pulmonary capillaries. Thence it breaks 
through into the alveolar spaces and is coughed up, passing HOOKWORM DISEASE 
227 
with the mucus into the intestines. During its passage 
it increases in size, until it is of practically adult dimensions 
by the time its final habitat is reached. 
Diagnosis.—In many persons there are few, if any, 
clinical manifestations of hookworm infestation. Usually, 
however, there are signs of anemia, malnutrition, mental 
retardation, or intestinal involvement of some kind. The 
blood presents a picture of secondary anemia and the 
differential count shows a slight increase of eosinophiles. 
Our main reliance is upon the stool examination, which will 
show the eggs in varying numbers. Under the low power 
of the microscope these have the appearance of large brown 
ovals, with a clear outer shell equal in thickness to about one- 
eighth of the short diameter, and with what resemble 
nuclei grouped in the center, numbering from four to 
sixteen. A further aid to diagnosis is the appearance in 
the stools of adult worms, from one-half to three-quarters 
of an inch long, after administration of a dose of thymol, 
followed by Epsom salts. 
Methods of Control.—Knowing as we do the complete 
life history of the parasite, its eradication appears to be 
simple. But we are hampered by public indifference and 
ignorance (just as in malaria) which is particularly marked 
among the very classes which suffer most heavily from 
hookworm disease. 
Sanitary privies, or complete sewerage, used by the entire 
population at all times, would almost entirely prevent the 
transmission of hookworms. Universal wearing of shoes 
would largely prevent the entrance of the larvae into the 
body. But the method of control which has been found to 
be most practicable and effective, by those who have had 
the widest experience, is to make these measures secondary 
to treatment of the human host to rid him entirely of 
parasites. Feces control without treatment will not eradi- 228 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
cate the disease; treatment without feces control will not 
prevent re-infestation. 
This procedure has had an educational influence upon the 
affected populations which has tended to maintain the 
preventive measures which have been established. But 
such a campaign must be thorough and planned to cover a 
period of years, until the entire population can be examined 
and treated. Once they have been freed of their parasites, 
there is such a marked improvement in physical activity 
and intelligence that there is less tendency to revert to 
former careless and insanitary ways. 
Mortality.—Few persons die directly of hookworm dis- 
ease. Its accompanying anemia, however, lowers vitality 
and opens the way for other infections and diseases. 
Hookworm disease has an economic importance that ranks 
it practically with malaria in countries that are heavily 
infested. This fact has been recognized by governmental 
agencies in many parts of the world, and has resulted in the 
initiation of eradicative measures of great magnitude. 
Notable also is the work of the International Health Board 
of the Rockefeller Foundation, which has operated in our 
southern states for several years, and is extending its 
activities to many tropical and subtropical lands. 
13. IMPETIGO 
Impetigo contagiosa is an inflammatory skin disease that 
is frequently seen among children of school age and less 
commonly in adults. 
Infective Agent.—No agreement has been reached as to 
the specific organism responsible. Streptococci in pure 
culture have been recovered from the lesions in some cases, 
while staphylococci have been found associated in others. 
The disease can be reproduced from the exudate. IMPETIGO 
229 
Incubation Period.—The time required for incubation is 
unknown. 
Immunity.—Well-nourished persons of cleanly habits 
are less prone to acquire the disease than others. 
Modes of Transmission.—Contaminated fingers and 
common towels are probably the two commonest vehicles of 
transference. A patient often re infects himself by scratch- 
ing. Crowded, insanitary living conditions favor the 
transfer of infections such as this, due to lack of personal 
cleanliness and the common use, by a number of persons, 
of such articles as towels, wash basins, brushes, etc. 
Schamberg mentions twenty cases of impetigo, coming 
under his own observation, which all appeared to have been 
contracted in two days at a barber shop. All of these 
patients had the services of the same barber. 
Diagnosis.—In impetigo there are initial vesicles which 
are small, flat and very thin walled, without any reddened 
areola, such as is seen in chickenpox. They prefer the 
exposed surfaces of the body, especially about the mouth. 
When a scab has formed it is flat and tends to curl at the 
edges, giving an appearance of having been “stuck on.” 
The disease is often continued by the patient himself 
infecting other parts of the skin. 
Methods of Control.—Perhaps the quickest means of 
controlling the infection is by curing all cases that are found. 
This is easily accomplished in two or three weeks by proper 
treatment. Here again the need of a free clinic is empha- 
sized, for the disease is most common among those who are 
unable to pay medical fees. Children suffering from the 
disease should be excluded from school until cured, unless 
under adequate, continuous treatment. 
Mortality.—Occasionally, an outbreak of impetigo in an 
institution for infants becomes quite virulent and causes 
some deaths. Otherwise there is no mortality. 230 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
14. INFLUENZA 
From remote times and through succeeding centuries 
to the present day, the world has repeatedly suffered great 
epidemics of influenza. Sweeping periodically from east 
to west, these pandemics have cost millions of lives and 
for the civilized world today the disease continues to be the 
greatest unsolved plague. Practically each recurrence 
found the disease designated by a new name, until it was 
carefully studied and described as a definite pathological 
entity, apparently always present to some extent in all 
communities, and was named by the French “La Grippe” 
and by the English “Influenza.” We have shortened the 
French term to “grip” and it has come to mean almost any 
kind of a cold, in popular terminology. But sight should 
not be lost of the fact that all modern textbooks on medi- 
cine use “la grippe” and “influenza” synonymously, 
and the promiscuous application of these terms to all mild 
affections of the respiratory tract should be discouraged in 
the interest of correct nomenclature. 
Infective Agent.—That there is a specific organism cap- 
able of reproducing repeatedly the disease entity called 
influenza we cannot doubt. But its nature has not yet 
been determined. Some evidence seems to point to the 
Pfeiffer bacillus, or B. Influenzae, while other work would 
tend to indicate a filterable virus. One great life insurance 
company has supplied funds for an exhaustive study by a 
commission, composed of some of the leading experts of the 
country, from which we may hope for valuable results. 
In addition, many independent investigators are at work 
upon the problem.1 
Modes of Transmission.—Since the disease affects the 
respiratory tract primarily in the majority of cases, it is 
1 The Rockefeller Research Institute has recently announced the discovery 
of a minute coccus that may be the causal agent. INFLUENZA 
231 
reasonable to suppose that its spread is accomplished 
through droplet infection, while transference by the hands, 
by articles soiled with saliva and by kissing are also impor- 
tant. Exhaustive research in army camps and industrial 
plants, stores and restaurants points strongly to hand con- 
tamination as the principal mode of transmission. In the 
intestinal form the dejecta probably are infective. Because 
of the widespread prevalence of the disease, many have 
been lead to believe that it is “air-borne.” But a careful 
study of the first cases appearing in a community has 
repeatedly demonstrated that contact between the sick 
and the well has occurred in practically every instance, 
and usually in the early stage, before the patient suspected 
that he had influenza. 
The marked periodicity of influenza epidemics is an 
interesting feature. Large outbreaks occur approximately 
at intervals of a generation and last over a period of several 
years, during which time there seems to be a periodicity 
of about thirty-three weeks between successive peaks. 
The intensity of peak rises in the subsidiary outbreaks 
appears to be greater or less according to season. Each 
individual outbreak is ordinarily limited in duration to 
about a six weeks’ period, from onset to subsidence. Its 
intensity seems to depend upon certain factors related to 
the crude death rate and the rates for tuberculosis, organic 
heart disease and nephritis. The higher these rates are, 
the more severe is the influenza epidemic. What bearing 
these various factors have on susceptibility has not as yet 
been determined, but they lead to interesting speculations 
which may bear fruit in time. 
Immunity.—Apparently no one is naturally immune, 
the disease attacking the lower age groups principally for 
the reason that older persons have had previous attacks. 
Repeated attacks in the same individual are quite common, 232 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
however, although one attack seems to confer a relative 
immunity upon the majority of persons. 
Incubation Period.—Two to four days is the period 
required for incubation, with a larger percentage of cases 
developing in the shorter time. 
Diagnosis.—Space need hardly be given to the subject of 
differential diagnosis, as it is one that is all too fresh in the 
minds of physicians today. A word of caution should be 
uttered against the prevailing tendency to diagnose every 
case of generalized body pains with fever as “flu.” Since 
the passing of the pandemics, the authors have noted that 
several cases of smallpox have been allowed to spread infec- 
tion by reason of such error in recognizing the prodromal 
symptoms. 
Methods of Control.—One of the most widely debated 
topics of the day among sanitarians is the best method of 
controlling an outbreak of influenza and, judging from 
recent experience, the question can hardly be regarded 
as settled. To the frank case, in bed, can be applied the 
usual procedure of isolation and concurrent disinfection, 
while the immediate contacts can be held in quarantine for 
four days. But all of us have become familiar with the 
many mild and missed cases that are found abundantly 
and with the fact that nearly all cases, which later become 
well marked, are usually up and about during the prodromal 
stage. It is by reason of these facts that the disease 
gains such rapid headway in spite of our best efforts to 
control it. 
At present the chief methods available for the health 
officer are (1) isolation of cases when found; (2) quarantine 
of contacts; (3) [education of the public to remain at home 
upon the first appearance of suspicious symptoms, and (4) 
organization of the community for both relief measures 
and for the discovery of unreported cases. As a result 233 
INFLUENZA 
of the thorough application of these principles, mortality 
at least, can be reduced and the case incidence spread 
out more evenly, thereby rendering it possible for relief 
agencies to reach all of those needing aid. In controlled 
groups, such as mines, factories and schools, daily inspec- 
tion of all persons, by physicians or nurses, with isolation 
of suspicious cases, gives excellent results, provided that the 
chances for outside contact are reduced. In any event, 
such measures eliminate opportunities of acquiring infec- 
tion while at work or at school and will safeguard those 
who otherwise make an effort to avoid exposure. 
When all of the possible chances of exposure for a given 
individual are considered, the closing of places of public 
gathering hardly seems justifiable. If the other measures 
above suggested are faithfully carried out, strict closing of 
public places appears to have little effect upon the spread 
of infection, certainly, at least, in large centers of popula- 
tion. This is particularly true of schools, where daily 
inspection and the exclusion of suspects afford the children 
better protection and furnishes the health officer with 
information as to early cases. Doubtless, the ban on public 
gatherings will temporarily diminish the amount of the 
disease appearing, but will not prevent the ultimate infec- 
tion of susceptibles, by reason of the fact that limitless 
chances for contact are everywhere present. The incon- 
venience and expense resulting from closing, therefore, do 
not justify the results obtained. This was well illustrated 
in one town under observation, during the epidemic of 1920, 
where the cases at no time reached a high peak comparable 
with other communities in the state, although all places of 
public gathering in the town were allowed to remain open. 
However, the other control measures above mentioned were 
effectively carried out. It is also interesting to note that 
other communities, where closing was rigorously enforced, 234 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
during the general epidemic and which suffered only lightly 
at the time, had well marked outbreaks, as soon as restric- 
tions were abated. In small rural communities, however, 
closure no doubt materially reduces the amount of contact, 
and so may be of value in distributing the peak load of the 
epidemic, if other control measures cannot be applied. 
Mortality.—Deaths from influenza are rather infrequent 
as compared with those from the resultant pneumonia. 
It is toward the prevention of the latter complication 
that the health officer should especially bend his energies. 
Education of the people to protect themselves by going to 
bed early and securing adequate nursing care will do much 
to reduce this mortality. It is here that community 
relief measures, well organized beforehand, find their 
highest usefulness. Such an organization should develop 
around the health department as a center, in order that the 
health officer may guide it into proper channels and prevent 
the adoption of fads that waste time and money. We have 
come to the general conclusion that, while we are rather 
helpless to prevent cases, yet by proper organization of 
medical, nursing and other relief services we can materially 
reduce the mortality in epidemics. A plan of community 
relief organization for epidemics, designed with this purpose 
in view, will be found in the appendix. 
A judicious use of antipneumococcus vaccine as a pro- 
phylactic against the subsequent pneumonia, with the full 
understanding that it will not prevent influenza, seems to 
reduce the mortality somewhat. 
15. LEPROSY 
From the earliest recorded history of China, India, 
Syria, Egypt and Palestine, down through the ages to our 
own day, the word “leper” has roused a shudder that no 
other disease inspires, by reason of the loathsome picture LEPROSY 
235 
of decaying human flesh that it recalls. From Iceland 
to the tropics and from east to west, the leper can be found 
in varying numbers. In New England, Louisiana and 
California are found endemic centers of the disease that 
have existed for years. Dr. Frederick L. Hoffman has 
made the latest and most accurate survey of leprosy in the 
United States. He places the entire number of cases at 
not less than 400 and probably closer to 500. 
While such a small number in itself would not be alarm- 
ing, Dr. Hoffman points out that leprosy is insidious in its 
spread and that endemic foci may be established before we 
are aware of the danger, unless preventive measures are 
instituted. Once having seen a case, no one would hesitate 
to take every possible step to control the spread of such a 
disease. To quote Manson, “ altogether, the blind, lame, 
unhappy wretch, still retaining his intellect, but devoid of 
every sense except that of hearing, breathing with difficulty 
through a stenosed larynx, and racked by neuralgic pains 
and irregular outbursts of fever, comes to present, before 
the inevitable death from exhaustion occurs, a sadder, more 
loathsome, and more repulsive picture than anything 
imagination could conceive.” 
Infective Agent.—There is some disagreement among 
authorities as to the discoverer of the specific organism of 
leprosy, but it would appear to have been identified in the 
period of 1870 to 1880, thus making it one of the earliest 
bacteria definitely associated with the disease which it 
produces. The Bacillus leprae has been generally accepted 
as the infective agent of leprosy, but several forms, either 
variations of the one organism or different species, have 
been observed. Animal inoculations have so far failed to 
solve the problem definitely and our principal evidence of 
specificity rests upon the constant presence of the bacillus 
in all leprous lesions, as well as in the blood in some cases. 236 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
The bacillus has also been found in the sputum and in the 
intestines, but not in the urine. 
A feature of especial interest is the fact that the bacillus 
behaves much like the tubercle bacillus in staining char- 
acteristics and that the disease has many points in common 
with tuberculosis. In stained section of tissue the bacilli 
are often found arranged in a group resembling a bundle 
of cigars and lying within the cell. No other organism 
presents this peculiar grouping. 
Incubation Period.—As in tuberculosis, leprosy appears 
to have a prolonged incubation, or latency, period. But 
its gradual onset makes impossible any definite determina- 
tion of the exact time of infection. Figures varying from 
2 to 27 years are given, but are unreliable. 
Immunity.—In times past leprosy spread rapidly among 
non-immune people and even in recent decades it has devas- 
tated large groups. At present, we may say that an 
extremely high degree of immunity exists in nearly all of 
the world, although Dr. Hoffman’s careful study indicates a 
slight increase of incidence in some quarters. It is possible 
that resistance has gradually been bred into the race 
through a long continued selective action. 
In general the disease makes its appearance between the 
ages of 10 and 30. Whether infection usually takes place 
in early childhood, as commonly believed of tuberculosis, 
is a matter of conjecture. 
Modes of Transmission.—No experimental evidence 
has been obtained to demonstrate the mode of transmission. 
Several instances are recorded in which the disease could be 
traced definitely from a given individual to another person; 
indeed, through an entire tribe in one case. Such facts lead 
us to believe that contact plays the chief role in infection. 
This is reasonable to suppose, when we consider that 
the bacilli are found abundantly in the nasal secretions LEPROSY 
237 
and in discharging lesions of leprosy cases. Whether 
transmission is through sputum spray, or by direct inocula- 
tion of wounds, or by ingestion of bacteria, is unknown. 
Diagnosis.—For a detailed discussion of diagnosis refer- 
ence must be had to such works as are mentioned in the 
appendix, for the disease assumes many forms. Its 
principal sign is the development of anesthetic areas on 
the skin, which may be preceded by sensory disturbances of 
several kinds in the parts involved. A pale or pigmented 
spot, usually upon the trunk, face or extensor surfaces, the 
center of which is insensible to pain or touch, may be con- 
sidered as pathognomonic, when accompanied by a sugges- 
tive history. Another feature often noticed is frequent 
nose-bleed and an ulceration of the cartilagenous septum of 
the nose. In the pure tubercular, or nodular type, it may 
be necessary to rely entirely upon history and microscopic 
findings during the early stages. Cases of the nerve type 
present thickenings along the larger nerve trunks that appear 
quite early. This can usually be demonstrated easily on 
the ulnar nerve just above the inner condyle of the humerus. 
The bacilli may be aspirated from a nodule by injecting 
a few drops of saline solution into it with a hypodermic 
syringe, and repeating the injection and withdrawal of 
fluid a few times. The solution is then spread upon slides 
and stained in the usual way. 
Leucoderma is to be distinguished from leprosy by the 
presence of tactile sense in macules of the former disease. 
Syringo-myelia is sometimes confused with leprosy, but 
is distinguished by the absence of macules, of thickened 
nerve trunks and of enlarged lymphatic glands. Vitilligo 
may resemble leprosy, but is not anesthetic. 
It should be urged, then, that a case giving a history of 
slowly progressive debility, often with remissions, and 
presenting nodules or macules upon some part of the body, 238 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
should be carefully studied for the possible presence of 
leprosy. 
Methods of Control.—The only method of control that 
is a real safeguard to the public and humane to the patient 
is segregation in a leper hospital, where the victim may 
receive treatment and proper care until cured or death 
relieves his misery. Isolation is obviously necessary, 
but isolation for life, at home, is generally out of the ques- 
tion. The infective discharges must also be cared for 
and this cannot properly be secured over such an extended 
period, without supervision. 
Fortunately, Congress has provided the funds whereby 
the U. S. Public Health Service will be enabled to care for 
such lepers as may become a menace that cannot be con- 
trolled by the individual states. Plans are under way for 
the erection of a national leprosarium that will solve a 
vexing problem for this country. 
Meanwhile, the leper must be held in such isolation as 
the local government can provide, receiving every possible 
care and consideration. The most feasible method, where 
a leprosarium is not available, is restriction of the patient’s 
movements to the vicinity of his own home; exclusion from 
public gatherings and from occupations connected with the 
handling of food or domestic employment, and regular 
reporting by the leper to the local health authorities. 
If the latter fail to receive a personal report from the indi- 
vidual at the usual time, investigation should be made at 
once and steps taken to apprehend him, if he has departed 
from the health jurisdiction. 
Mortality.—In the Louisiana Leper Home, for the period 
December 1894 to December 1915, 43.2 per cent, of the 
cases received have died, while 7.4 of all cases have been 
discharged as cured. It may be said that at least 90 
per cent, of all cases will die of leprosy or intercurrent MALARIA 
239 
mfections more or less connected with the disease. Some 
hope, however, of lowering this mortality has been roused 
by the work done in some of the larger colonies, where 
treatment seems to be making an impression upon many 
cases. Meanwhile, the medical profession should become 
sufficiently familiar with the signs of leprosy to make a 
tentative diagnosis, especially in those localities where 
cases are known to exist. 
16. MALARIA 
Somewhat over 2000 years ago, the first references to 
malaria made their appearance in Greek and Roman writ- 
ings. It has been inferred that the disease was brought 
into these countries by returning soldiers or slaves. By the 
first century B. C. it had become so well established that 
medical writers distinguished the various types of infection 
and referred their origin to marshes and other wet places. 
Malaria has played a prominent part in the histories of 
many nations and in their various undertakings. It has 
insidiously sapped the vigor of those that were once domi- 
nant in the world and may have contributed largely to their 
downfall. Some of the most fruitful places of the earth 
have been desolated by the ravages of malaria, coupled 
with yellow fever, until they have become bywords of 
pestilence and death. Our own Canal Zone was such a 
place until Gorgas transformed it. Even yesterday Guya- 
quil, Ecuador, bore the same unsavory reputation. 
No discussion of malaria is complete without a reference 
to Sir Ronald Ross, of England. Working in a little 
laboratory in India, tried by many disappointments, 
his work ignored, often compelled to drop his studies 
for other duties, he still persisted in an apparently fruitless 
search until, on the 20th of August, 1895, he saw for the 
first time a malarial parasite in the process of development 240 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
in a mosquito. The problem of transmission had been 
solved and a fact of inestimable value to the world had been 
firmly established. The story of his labors, as recounted 
in his own original work upon the subject, is a romance of 
science that should be read by every sanitarian. 
To write anything approaching a full discussion of the 
subject is beyond the scope of this chapter. We can merely 
touch upon the important phases in outline form. 
Infective Agent.—Laveran, working at Constantine, 
first discovered the specific organism of malaria in Novem- 
ber, 1880. His work was followed by many others until the 
entire life cycle of the parasite in man had been described. 
But it remained for Ross to demonstrate that there were 
two phases of the life cycle, one in man and the other in 
mosquitoes. 
Various names have been applied to the species, the most 
common of which was plasmodium malariae. Today the 
accepted designation is hemameba. There are three varie- 
ties recognized at present and corresponding to the types 
of fever that have long been known. They are H. vivax 
(tertian), H. malariae (quartan) and H. falciparum (estivo- 
autumnal). The parasite is a protozoon, similar in many 
respects to amebae. As suggested above, it passes through 
two distinct life cycles dependent upon the kind of host 
which harbors it. In man the phase is entirely asexual, 
reproduction taking place by both simple division and 
mitosis. Sexual forms are produced in human blood, 
but do not reproduce, so far as known. When taken into 
the stomach of a mosquito, however, they pass through a 
stage of development quite different from the other and 
are again ready for an asexual career in another human host. 
As successive crops of parasites are thrown into the blood 
stream, we see the intermittent attacks of chills and fever 
so characteristic of the disease. The parasite grows only MALARIA 
241 
in or on the red blood cells and it is the destruction of the 
latter, with a probable liberation of toxins, which produces 
the usual symptoms, including anemia. 
Many attempts have been made to find the organism 
in marsh water and to produce the disease by drinking 
such water or introducing it into the body in other ways. 
No such attempt has ever been successful. The hemameba 
lives only in the animal body and in that of the mosquito. 
For a description of the parasite as found in human 
blood, reference should be made to any standard work on 
pathogenic microorganisms. 
Incubation Period.—Experimental work throws no defi- 
nite light upon the length of incubation. It is probable 
that several factors contribute to the development of an 
attack of fever, such as the number of parasites received, 
natural resistance, etc. We do know that experimental 
inoculations have shown incubation periods running from 
5 days to several weeks. 
Immunity.—It appears that no natural immunity to 
malaria exists. Certain persons seem to repel mosquitoes, 
due probably to body odors. Many who live in malarious 
regions acquire infection in infancy, gradually becoming 
immune. 
Quinine taken regularly will produce artificial immunity 
so long as continued in sufficient dosage. The amount 
required depends somewhat upon the degree to which 
mosquitoes and malaria carriers prevail. 
Modes of Transmission.—Aside from a few rare cases 
acquired in the course of blood transfusion, malaria is 
always transmitted by a mosquito. Moreover, only one 
sub-family of these insects is capable of this transfer, 
viz., anophelinae. There are about 25 recognized species in 
this group which may be vectors of malaria. They are 
commonly called the anopheles mosquitoes and have 242 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
certain characteristics which distinguish them from others, 
as follows: 
1. When the mosquito is resting upon a flat surface, 
the body is directly in line with the head and tilted at an 
angle of about 45°, instead of being bent downward so as to 
be parallel to the surface upon which the insect is resting. 
2. The larvae lie parallel to the surface of the water, 
instead of at right angles, with the head down. 
3. Wings are spotted. 
4. Proboscis is in line with the body axis, when resting. 
5. Palpae about equal in length to proboscis in both 
sexes. 
6. Distinctly night flying. 
Only the female has a taste for blood, which is necessary 
to the development of the eggs. She seeks man or other 
animals to satisfy this appetite and then flys to a convenient 
collection of water to deposit her eggs. The favorite 
spots selected are along the protected banks of sluggish 
streams, in ponds and in quiet pools or the water of empty 
cans, barrels, roof gutters, etc. In favorabe weather the 
young reach maturity within ten days, whereupon the 
females among them seek their fill of blood again. 
When the mosquito withdraws blood from a malaria 
carrier or case, she usually receives a few of the sexual 
forms of parasite above mentioned. The male element 
undegoes certain changes by which parts of its body, 
corresponding to spermatozoa, are thrown off. These 
actively motile cells conjugate with the female bodies 
and a new generation of hemamebae is produced. They 
find their way into the so-called salivary gland of the mos- 
quito and are injected beneath the skin of the next person 
attacked. The entire cycle in the mosquito requires from 
7 to 10 days for its completion, and longer, if the weather 
is cool. MALARIA 
243 
Thus we see that malaria really is associated with swamps 
and other wet places, but in a manner quite different from 
that formerly supposed. 
Diagnosis.—In many parts of the United States malaria 
has been so common that physicians have frequently 
acquired the habit of calling any protracted fever or any 
debilitated condition “ malaria.” While a typical case can 
be diagnosed by clinical symptoms, as a rule, yet many an 
atypical case has been overlooked and many other condi- 
tions have been erroneously classed as malaria. In the 
minds of many there seems to be a hazy notion that malaria 
simply designates any vague group of symptoms having 
fever and lassitude as their principal features. Yet the 
majority of cases can be easily diagnosed by a simple 
microscopic examination of the blood. -Any public health 
laboratory can usually do the work in 15 minutes and 
physicians should acquire the habit of using the microscope 
themselves or of sending a specimen to the laboratory 
before diagnosing malaria definitely. It should always be 
borne in mind that even 2 grains of quinine will temporarily 
drive the parasites from the peripheral circulation. If the 
drug has been taken, a wait of 48 hours, or longer, should 
elapse before an attempt at microscopic examination is 
made. 
Another feature of importance in malaria is the enlarged 
spleen. This is taken advantage of in making a rapid 
survey of children for infection. 
Methods of Control.—Three general lines of activity 
present themselves as available in whole or in part for the 
control of malaria. They are mosquito eradication, screen- 
ing and quinine prophylaxis. 
l Since the mosquito must have quiet water for the 
development of the larva and pupa, drainage offers an excel- 
lent means of control. When drainage cannot be accom- 244 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
plished, it is possible to take advantage of the fact that 
the larva is an air breather and a film of oil is floated over 
its habitat, killing it by suffocation. It is also practicable 
to use a poison for the larvae in some areas. Again certain 
kinds of fish eat the larvae readily and can keep a pool of 
water clear of them, if the edges of the pool are cleaned 
thoroughly of all protecting vegetation. Many small 
collections of water can be removed by filling all depressions 
in the ground surface. About the premises of a house are 
many accumulations of standing water that require empty- 
ing or screening, if mosquitoes are to be wholly eradicated. 
An old tin can full of water will breed hundreds of the pests 
in a season. 
Screening prevents the mosquito from reaching those who 
are well and from acquiring parasites from the sick. It is 
an excellent measure that has accomplished a marked 
reduction in malaria incidence wherever thoroughly applied. 
But it must be thorough to be effective. A screen of 16 
meshes to the inch is necessary to keep out anopheles and 
no breaks or cracks can be left anywhere. Even the chim- 
ney must be screened in places where mosquitoes abound. 
Not only should the house be screened, but netting should 
be used over the bed, for anopheles bites a sleeping person by 
preference. Netting so used should be tucked in under 
the mattress and should have no break in it anywhere. 
In some places quinine prophylaxis alone has been exceed- 
ingly effective in reducing malarial infections. To be 
worth anything at all, the drug must be taken constantly 
during the mosquito season. In the malaria patient it 
keeps the peripheral circulation free of parasites and in the 
non-infected individual it is distinctly a preventive. 
Observers in highly malarious regions have noted that larger 
doses of the drug are needed to produce this effect than 
would be required in districts of moderate or low incidence. MALAEIA 
245 
The average effective dose is 5 to 7 grains daily for as long as 
the mosquito is present. An exceedingly important point 
in the control of malaria by the use of quinine is the com- 
plete sterilization of cases as far as the parasite is concerned. 
Too often the physician or patient relies upon the disap- 
pearance of symptoms as an indication of cure of the case, 
when in reality the parasites have only been diminished 
in number. Treatment should always be continued over 
a sufficient period of time to make certain that the destruc- 
tion of parasites is complete, and the microscope should be 
used as a check. 
Many factors must be considered before any one or all 
of these measures are applied. The amount of infection is 
important, as extensive drainage operations might not be 
justified in the presence of a light infection, while it would 
easily repay the cost in other localities. Intelligence and 
cooperation on the part of the community would affect the 
success of wholesale screening or quinine administration. 
Economic considerations often enter in, such as the loss of 
productiveness of land due to physical disability of the 
occupants or removal of tenants on account of malaria. 
The question would arise, whether increased production 
would offset expense of preventive measures. These serve 
to illustrate the fact that an experienced engineer should 
be consulted before other than the simplest measures are 
attempted. 
For a complete statistical study of various phases of the 
problem reference should be had to the excellent essay of 
Frederick L. Hoffman, “A Plea and A Plan for the Eradica- 
tion of Malaria” (Prudential Insurace Company). 
Mortality.—Ross states that in India alone malaria has 
an estimated death rate of 5 per 1000, or total deaths of 
1,130,000 annually. While not so great as this, the mor- 
tality in our southern States is high, And we must add 246 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
to this a host of anemic, debilitated persons who will fall 
easy victims to other diseases. 
Aside from its mortality malaria is a prominent cause of 
economic loss to the nation by reason of sickness and 
reduced efficiency. Wherever it is found the unhappy 
sufferers should be given the benefits of all that science 
has learned concerning the eradication of this plague, for 
it is preventable, if intelligently and persistently attacked. 
17. MALTA FEVER 
Generally speaking, Malta fever is quite rare in the 
United States, but it holds an especial interest for the states 
on the southern border in that it prevails to some extent in 
Mexico. The disease is so named from the fact that its 
greatest incidence is in Malta and along the Mediterranean 
littoral. But many cases are found in India, China, the 
West Indies, Brazil and elsewhere. While not the cause 
of any appreciable mortality, Malta fever is extremely 
debilitating, producing considerable economic loss to the 
patient thereby. It is also confused with other diseases, 
especially in its early stages, so that the possibility of its 
presence in certain localities should be kept in mind. 
Infective Agent.—Bruce, working in Malta, demon- 
strated the specific organism of Malta fever in 1887. To 
it was given the name Micrococcus melitensis, because of 
its minute, globular form and the most prominent focus of 
the disease. 
The organism is common to both man and the goat. 
In the former it may be found in the blood stream, during 
an acute attack, while it is present in the urine and in 
nearly all of the organs, at any time during the course of 
infection. Goats carry the micrococcus in the same 
manner and discharge it through the urine and milk. MALTA FEVER 
247 
Sunlight and drying are fairly destructive to the organism, 
but it can survive in milk and water for several days. 
Immunity.—Some difference of opinion exists as to the 
immunity produced by an attack of Malta faver, probably 
due to recurrent attacks in the majority of patients. 
However, a moderate degree of immunity results from 
vaccination with a killed culture of the micrococcus, so 
that we are led to infer such an action from an attack of 
the disease. The facts in this respect have not been fully 
established as yet. 
Incubation Period.—Many persons appear to carry 
latent infection for a considerable period, so that no definite 
statement as to the incubation period can be given. We 
do know, however, that some cases have developed within 
six days after the patients had taken up residence in Malta. 
Modes of Transmission.—Most important of all media of 
transmission is the milk of an infected goat. In this 
manner the disease has been kept alive for generations 
along the Mediterranean. In the southwestern United 
States cases have been reported in persons engaged in goat 
herding and the disease is known to prevail among goat 
herds in New Mexico, Texas and Mexico. 
The infective agent is also discharged in the urine of 
goats and may survive in water for a short while, so that 
we can, at least, suspect ponds of standing water that are 
used for drinking purposes, by both man and goats, as 
being the occasional source of a case. 
Contact cannot be wholly eliminated, although the 
evidence for its effectiveness in spreading the infection is 
scant. Patients suffering with the disease are known to 
discharge the micrococci in their urine and may thus 
contaminate articles handled by other persons. 
Diagnosis.—The early stages of a case of Malta fever are 
quite similar in many respects to typhoid fever. Initial 248 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
temperature, headache, anorexia, are identical. Rose 
spots, however, are absent and constipation is present, 
offering a hint at the differential diagnosis. As the disease 
progresses, the fever declines by gradual steps, quite unlike 
typhoid. Often, pains similar to rheumatism develop 
and the joints may be affected exactly as in acute arthritis, 
with one after another partaking of the inflammatory proc- 
ess. Neuralgic pains and orchitis are also frequent accom- 
paniments of the more chronic stage of infection. Attacks 
of fever alternate with periods of apyrexia, or the tempera- 
ture may be remittent. Occasionally cases present a 
continued fever for weeks, similar to a septic process. 
Malaria and tuberculosis must be distinguished from the 
disease. This is usually easy, after the process has con- 
tinued for a few weeks. 
In the laboratory a blood test similar to the Widal for 
typhoid fever will offer indication of the nature of the 
infection, by the end of three or four days after acute 
symptoms have presented. Blood culture is also positive 
during this state. 
The outstanding features of diagnosis are remittent, or 
intermittent, fever, pains of rheumatic nature, neuralgia, 
orchitis, splenic enlargement, extreme debility, and a 
course extending over months or years. 
In addition, a history of using goat’s milk, or of having to 
do with the care of these animals, is suggestive. 
Methods of Control.—Since goat’s milk is by far the most 
important vector of M. melitensis, the proper control of this 
food will check infection of human beings. A herd that is 
suspected should be examined by bacteriological methods, 
remembering that 50 per cent, of goats show no signs of 
disease. All animals found to be harboring the organisms 
should be isolated or killed. If killed, their meat should be 
thoroughly cooked before being used for food. Milk of MEASLES 
249 
segregated animals should be kept entirely separate from 
that of the rest of the herd and should be boiled before being 
used for any purpose, including the feeding of other goats. 
Kids from infected mothers should be segregated imme- 
diately after birth and examined for infection. They 
should be fed only pure milk, if found not to be infected. 
Patients suffering with the disease should be instructed 
as to the disinfection of the urine. 
Water used by human beings for drinking purposes 
should be fenced to prevent contamination by goats. 
Mortality.—The mortality of Malta fever is quite low, 
not running over 2.5 to 3 per cent, of cases. Its debilitating 
nature, however, would predispose to other infections, 
aside from lowering efficiency and causing economic loss. 
18. MEASLES 
Since smallpox has been brought under greater control, 
measles deserves first rank among infectious diseases in the 
number of cases arising from it in the United States and 
Canada. For only a negligible portion of the population 
is naturally immune and the mortality caused by measles 
is higher than is commonly believed. 
Infective Agent.—While the specific organism has not yet 
been isolated, considerable laboratory work has demon- 
strated that it is carried in the blood, just before and after 
the eruption appears, and that it is found in the saliva at 
about the same time. 
Incubation Period.—Following the injection of infected 
blood into monkeys, a period of fourteen days elapsed 
before the exanthem was detectable. Consonant with this, 
epidemiological investigations have shown that approxi- 
mately ten days intervene from the date of exposure to the 
first symptoms and fourteen days to the rash, taking an 250 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
average of cases. There are a few days'variation on either 
side of this figure. 
Immunity.—Not more than ten per cent, of the popu- 
lation, at a liberal estimate, is naturally immune, including 
all ages. Immunity in the higher age groups is due to 
early infection. 
Modes of Transmission.—There is no valid evidence that 
there is a carrier problem in the transmission of measles. 
It is common experience, borne out by research, that the 
pre-eruptive stage is the most highly infectious and that the 
danger diminishes as the temperature returns to normal. 
It is extremely doubtful if the case is infective after the 
eruption is completely developed. The fine, branny scales 
that follow the disappearance of the eruption have been 
shown to possess no infectivity. It is the developing case, 
then, that distributes disease, often before a diagnosis 
is made. 
Droplet infection is probably the means by which the 
virus is transferred from sick to well, as it is quite common 
to have a history of a child playing with another who had a 
“cold.” Transference of the fresh virus by the hands, or 
by kissing, is also to be considered. 
Diagnosis.—There are two essential points with reference 
to diagnosis in measles. First, that it should be made 
early, and second, that differentiation should be made from 
other exanthemata. 
The fact that measles is most contagious for several days 
before the appearance of the eruption makes an early 
diagnosis imperative, in order that there be an early iso- 
lation. The presence of a punctate eruption on the palate 
and pharynx indicates oncoming measles. This eruption 
cannot be described easily, but once seen, it is never for- 
gotten. This prodromal eruption is distinct from Koplik’s 
spots, which are seen as the skin eruption develops. It MEASLES 
251 
should be recalled that Koplik’s spots are few in number; 
that they appear on the buccal mucous membrane opposite 
the biting edges of the teeth, and that they are small 
dark red spots with bluish white centers. Other prodromal 
symptoms, as coryza, inflamed eyes, a temperature of 
102-105 (which often remits on the day before the rash), 
must be considered in connection with the appearance of 
the palatine mucosa. 
The eruption on the' skin is characteristic and is 
described in all text books on medicine. It is sometimes con- 
fused with mild smallpox. But this should not occur if it 
is remembered that the latter gives a hard, shot-like 
swelling, while the measles rash has a soft, velvety feel, 
with very little induration. Distribution of the eruption 
in measles is on the face and trunk, primarily, while that of 
smallpox is on the face and extremities. 
Methods of Control.—Immediately upon recognition of 
suspicious symptoms, the patient should be isolated, particu- 
larly from non-immunes. Concurrent disinfection of all 
discharges from the nose and throat should be complete. 
Five days isolation, from the date of onset, is sufficient, as 
infectivity generally ceases within this time. 
Contacts who have not had the disease should be excluded 
from school and from public gatherings and separated 
from non-immune children. If it is possible to determine 
exactly the date of first exposure, a contact might safely be 
allowed full liberty, including attendance at school, for a 
period of seven days, as it has been satisfactorily demon- 
strated that infectivity does not begin in any case until a 
minimum seven day period has elapsed. He could then 
be quarantined for seven to ten days, which would allow of 
ample time for prodromal symptoms to develop. How- 
ever, this procedure can be used safely only by a well 
organized health department or school medical inspection 252 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
service. If the date of contact cannot be definitely estab- 
lished, it is safer to quarantine contacts for at least fifteen 
days. 
In the event that a case of measles develops in a school 
child, daily inspection of all other children, before they 
mingle in school, will help to suppress further spread. The 
teacher can assist greatly by excluding suspicious cases and 
no difficulty should be experienced in instructing teachers 
to recognize such symptoms as would justify exclusion. 
There must be continuous and positive education of the 
public as to the danger of exposing children to those who 
present symptoms of “cold.” That the child is “bound to 
get the diseases of childhood and may as well have them 
early,” is a popular fallacy that the health officer should 
combat. The longer the infection can be postponed, the 
lower is the death rate. 
Mortality .—There is considerable misunderstanding of 
the mortality of measles. While the disease itself does not 
often kill, its complicating pneumonia, together with other 
less frequent sequelae, produce a death rate among the 
acute contagious diseases second only to diphtheria and 
whooping cough. During the period 1910-1919, the death 
rates for the four principal diseases of this class, for the 
Registration Area of the United States, were: 
Diphtheria 16.75 per 1000 of population 
Whooping cough 10.3 per 1000 of population 
Measles 9.3 per 1000 of population 
Scarlet fever 5.6 per 1000 of population 
In 1917, there were 10,745 deaths recorded for measles, in 
the Registration Area, and this number was probably much 
lower than the actual deaths, as many physicians forget 
to enter measles as the primary cause of death, on the 
certificate, when the terminal cause is pneumonia. Health 
officers should abandon the old laissez faire policy of hand- EPIDEMIC CEREBROSPINAL MENINGITIS 
253 
ling measles and recognize it as an important cause, not 
only of deaths, but of subsequent physical defects. We 
are justified in combating this disease by every means in 
our power and should especially endeavor to overcome the 
public’s false conceptions concerning it. 
19. EPIDEMIC CEREBROSPINAL MENINGITIS 
Considerable confusion prevails due to the fact that the 
term “meningitis” has both a general and a specific 
meaning. In the former case it applies to any inflammation 
of the cerebral or spinal meninges, while in the latter it 
designates that disease which is caused by the meningo- 
coccus. It is in this specific sense that the term is used 
here. For want of a better name, we speak of “epidemic 
cerebrospinal meningitis.” In several features the disease 
is similar to poliomyelitis, particularly in respect of the 
widespread prevalence of carriers, as compared with cases, 
and in the periodicity of epidemics. On the other hand, 
our information as to epidemic meningitis is more complete 
than that on poliomyelitis. 
Infective Agent.—The organism producing epidemic 
meningitis is the Diplococcus intracellular is meningitidis, 
commonly called the meningococcus. Under the microscope 
it is indistinguishable, with ordinary stains, from the gono- 
coccus, being found within the polynuclear cells, as its name 
implies. The organism grows readily on properly prepared 
media, but dies quickly if allowed to dry. Hence it is 
necessary to transfer swabbings from the nasopharynx to 
the plates immediately. 
Incubation Period.—The incubation period is somewhat 
difficult to determine, as it varies within certain limits and 
some persons appear to carry the organisms for a considerable 
time before succumbing to infection. For practical public 
health purposes the limit is placed at 10 days. 254 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Immunity.—Susceptibility to meningococcus infection 
varies with the individual at different times and also with 
the strain of organism present. It is apparently affected 
by crowding, with its necessarily greater exposure, and by 
the number of cases prevalent at a given time. Also, 
persons coming from a locality that has been free from 
the disease for a period are more susceptible than those who 
live in communities in which it is more or less constantly 
present. For this reason, rural districts suffer more 
severely than do urban, in epidemic outbreaks. 
In the majority of cases, one attack appears to confer 
immunity. 
Some little work on prophylactic vaccination against the 
disease has offered encouragement for further study. 
Modes of Transmission.—Since the meningococcus is 
constantly found in the nasopharynx, sometimes in the 
anterior nares and mouth, and occasionally in the sputum, 
it would appear that the disease is acquired by droplet 
infection. It can be transferred on articles soiled with 
very fresh secretions of the mouth and nose, as well as by 
kissing. 
By laboratory examinations made in various outbreaks 
and at other times, it has been repeatedly shown that 
carriers outnumber active cases, sometimes to a marked 
degree. The convalescent case is always a carrier for a 
period of at least two weeks following subsidence of 
symptoms. * Practically all persons who have been in con- 
tact with a case are carriers for a period of two weeks to 
several months. These passive carriers give rise, in turn, 
to fresh secondary carriers, who, however, usually lose 
their virulent organism rather rapidly. But an endless 
chain is thus set up which may prolong the epidemic 
until all susceptible material is exhausted, if no control 
measures are instituted. EPIDEMIC CEREBROSPINAL MENINGITIS 
255 
Added to the carriers are the mild, missed cases, which 
are more numerous than is generally believed, particularly 
in an extensive outbreak. The two combined present a 
formidable problem to the health officer. 
Diagnosis.—A few diagnostic features of importance are 
enumerated below. Textbooks on the practice of medicine 
should be consulted for a more complete discussion. 
1. The patient becomes sick suddenly, with high and 
variable temperature, vomiting, rapid appearance of 
herpetic eruption on the lips, and signs of an irritative 
involvement of the central nervous system. There is 
usually some sore throat and a rash may appear, resem- 
bling some of the common eruptive fevers. 
2. After a day or two, lumbar puncture will reveal a turbid 
fluid under increased pressure. It is often possible to find the 
organisms in this fluid and to confirm the diagnosis at once. 
3. One writer has recently reported finding the diplo- 
cocci in the leucocytes of an ordinary blood smear. Whether 
this is constantly true remains to be demonstrated, but is 
worth investigating. 
4. If laboratory facilities are immediately available, a 
culture from the nasopharynx will often confirm the diag- 
nosis. It is important to note that in taking a swabbing 
for this purpose, the swab must be passed directly back 
to the posterior wall of the nasopharynx, either through 
the nose or behind the uvula, and immediately withdrawn, 
without being contaminated by touching other parts. The 
matter thus collected must be streaked on the culture 
medium at once. For a complete description of technique, 
see Simon’s Human Infection Carriers. 
It has been repeatedly observed that many inflammatory 
conditions of the throat prevail in the presence of an 
epidemic of meningitis. Whenever these cases have been 
studied bacteriologically, it has been discovered that 256 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
many of them yield cultures of the meningococcus. Thus 
it is apparent that such cases should arouse the suspicion 
of health officer and physician, for cases of this kind have 
often been shown to be the most likely sources of active 
cases of the disease. Positive diagnosis of these cases can 
be made only by laboratory examination, but, in the 
presence of an active case or an epidemic, such symptoms 
should lead to a provisional diagnosis of meningococcal 
infection, for the protection of the public health. 
Methods of Control.—Cases of meningitis must be 
strictly isolated and all discharges from the nose and throat 
burned. The nurse must attend carefully to the cleansing 
of her hands. Release of a patient should not be permitted 
until the throat is free of the organisms, or, if laboratory 
facilities are not availabe, until all symptoms have been 
absent for at least a week. 
The health officer’s most serious problem is the carrier. 
All persons who have been in contact with the patient 
must be quarantined until repeated laboratory tests show 
none of the organisms in the throat or nose. If a labora- 
tory is not accessible, such contacts must be held for at 
least ten days. Contact in this case should be held to mean 
every person who has in any way -been exposed to the 
patient, dating from about three days preceding the onset 
of symptoms. Careful inquiry should also be made among 
all associates of the patient for evidences of sore throat or 
for other indications of a mild attack of the disease. 
In the presence of a possible outbreak, the health officer 
can do much to lessen the prevalence of cases by educating 
the public in personal cleanliness, especially the avoidance 
of common cups and towels, as well as by efforts directed 
at the relieving of congested housing conditions. Prompt 
action at the first appearance of a suspicious case, coupled 
with the utmost energy and thoroughness in tracing MUMPS 
257 
all carriers, are the requisites for successful control of 
meningitis. 
Mortality.—In some outbreaks the mortality runs as 
high as 50 per cent, of cases. It varies, however, due to 
factors which are as yet little understood. Those who 
recover are often left with serious impairment of one or 
more of the special senses, or of the mentality. 
By preventing the development of secondary carriers, 
the health officer can do much to rob the disease of its 
terrors for the community at large. 
20. MUMPS 
Mumps is not of public health significance because of its 
mortality, which is negligible, but because of the protracted 
period of disablement resulting and the serious compli- 
cations frequently produced in the reproductive glands, 
leading sometimes to sterility. 
Infective Agent.—The specific organism has not been 
isolated, but it has been demonstrated that the secretions 
of infected salivary glands contain it and will transmit the 
disease. 
Immunity.—Before the age of five and after fifteen, there 
appears to be a decreased susceptibility. One attack 
usually confers immunity for life. Some promising work 
has been done recently which would indicate that artificial 
immunization may be produced by the use of convalescents’ 
blood. 
Incubation Period.—Epidemiological investigations have 
shown rather conclusively that the incubation period varies 
little from 21 days, although many textbooks still give it as 
ranging from 5 to 25 days. The latter figures are probably 
based upon faulty histories of exposure. 
Modes of Transmission.—It is quite apparent that 
infective saliva is the medium by which the disease is dissem- 258 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
inated. Droplet infection probably ranks first, followed by 
transference of the fresh virus on hands, articles used in 
common, and by kissing. 
Diagnosis.—Diagnosis presents no particular difficulty, 
once the swelling just below and slightly in front of the 
ear lobe has made its appearance. Combined with mod- 
erate fever and more or less pain on swallowing, it 
could hardly be confused with any other condition, except a 
possible abscess in approximately the same region. The 
submaxillary or sublingual glands alone may sometimes be 
the primary site of infection. 
Invasion of the testicles, ovaries or, occasionally, the 
mammary glands, should be guarded against. Also, a 
complicating mastoiditis, though exceedingly rare, must be 
borne in mind. 
Methods of Control.—The patient should be isolated 
from the first appearance of suspicious symptoms until 
the parotid and submaxillary glands show no further 
evidence of inflammation. This period may vary con- 
siderably in different individuals. 
Concurrent disinfection of discharges from the mouth, 
and of articles soiled with them, must be practiced. 
After 18 days have elapsed, from the date of first 
exposure, a non-immune contact should be quarantined 
for one week, if such a procedure is practicable for the 
health organization. Otherwise, quarantine should run 
for 22 days. 
Children showing suspicious signs should be immediately 
excluded from school and placed in provisional isolation 
and observation. 
Mortality.—As a result of mastoiditis or meningeal 
involvement, or due to heavy toxemias, a death from 
mumps may occur, but the general mortality of the 
disease is nil, PEDICULOSIS 
259 
21. PEDICULOSIS 
Infective Agent.—Three well defined varieties of pediculi, 
or lice, are recognized: the head louse, pediculus capitis; 
the body louse, pediculus vestimenti, and the one infesting 
the pubic region, phthirius inguinalis. The second of 
these is the far-famed “cootie,” that furnished exercise for 
the A.E.F., while at the front. In labor camps it is 
usually termed the “gray-back.” All three organisms 
belong to the same family, but have certain anatomical 
differences and each has a special habitat. The parasite 
produces an intense itching, at times, and the scratching 
of the affected parts eventually results in the formation of 
infected areas upon the skin. 
The head louse lays its eggs, commonly called “nits,” 
along the hairs, fastening them there with a sticky exudate. 
Crops of new parasites are constantly developing from these 
eggs. 
The body louse inhabits the seams of clothing worn next 
to the skin and comes out only to feed on its host. Its 
eggs are deposited in the clothing also. Only rarely is one 
of these parasites found on the skin, when a patient is 
examined, unless he is heavily infested. 
The pubic louse, or “crabs,” is found mainly in the hairy 
portion of the pubic region. It fastens itself to the hair 
and buries its head in the follicle. Eggs are deposited on 
the hairs, as with the head louse. 
Incubation Period.—The ova hatch out in from 5 to 6 
days. Sexual maturity, and reproduction of another 
generation, is reached in from 3 to 4 weeks. 
Immunity.-—Persons who are cleanly in their habits 
seldom acquire the condition. 
Modes of Transmission.—What is said of the trans- 
mission of scabies applies as well to pediculosis. Close 260 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
contact, or the wearing of an infested person’s hat, in the 
case of the head louse, is responsible for dissemination of 
the parasites. 
Diagnosis.—Diagnosis consists in finding the parasite, or 
its ova. Both are readily seen with the unaided eye. Ova 
on the hair slide along the hair shaft. 
Methods of Control.—Personal cleanliness is the principal 
method of prevention. Children who are infested must be 
excluded from school until free of parasites. There should 
be no exchanging of hats or use of common coat hooks in 
school buildings. Education of those who are neglectful 
of personal cleanliness is important in ridding a community 
of pediculi. 
Mortality.—There is no mortality from pediculosis. 
It is important to note that the body louse is the trans- 
mitting agent of typhus fever. 
NOTE: Methods of delousing are described in the 
appendix. 
22. PELLAGRA 
About 14 years ago the medical profession of the United 
States became alarmed at what seemed to be a marked 
increase in the prevalence of pellagra. Many theories of 
its etiology were advanced and much research work was 
done to determine its cause. From the mass of data 
collected then and since, we have come to believe that the 
evidence is rather convincing for food deficiency as the 
principal factor in the production of pellagra. Just why 
we should have beriberi in one case and pellagra in another, 
has not yet been answered. But that they are all prevented, 
or cured, by adding certain principles which have been 
lacking in the diet, seems to be established beyond doubt. 
It is, of course, a fact that a well developed case of 
beriberi or pellagra often responds only partially, or not at PELLAGRA 
261 
all, to such treatment. On first thought this would appear 
to refute the argument just mentioned. When, however, 
we examine the pathology of these affections, it is evident 
that no repair of permanently degenerated nerve tissue 
could be expected. And we do know that cases which 
show no signs of such permanent destruction can be cured 
in the manner stated, while communities in which the 
disease has regularly prevailed can be freed of it entirely 
by establishing the proper dietary regimen. 
Cause.—As has been suggested, the cause of pellagra 
appears to be a lack of certain “accessory food substances” 
in the diet. When these are supplied, the disease subsides 
and rapidly disappears from affected areas. 
Goldberger produced 6 cases of pellagra in a group of 11 
convicts by feeding them for 5 months upon a ration com- 
posed almost entirely of corn grits, sweet potatoes and 
gravy. It was just such a diet as is employed by a large 
portion of the population in our southern states, where the 
disease is most prevalent. Goldberger then cured his 
cases by feeding a well balanced ration. At the time of 
these experiments, he also rid some orphanages of pellagra 
by changing the diet, without making any other altera- 
tion in the mode of living or environment. 
While corn has frequently been incriminated as the causa- 
tive agent in producing pellagra, many have developed the 
disease who did not use this food at all. However, the 
disease has been largely associated with those regions where 
corn formed a large part of the diet and doubtless contrib- 
uted to disease production in a negative way by its 
universal use to the exclusion of other essential foods. 
Diagnosis.—Digestive disturbances, weakness, derma- 
titis and mental changes are the outstanding features of 
pellagra. Of these the skin lesion is most characteristic, 
appearing as a reddening of the epidermis, much resembling 262 
ELEMENTS OF FUBLIC HEALTH ADMINISTRATION 
sunburn. This may progress to a marked inflammatory 
reaction, with the formation of scales, blebs, small ulcera- 
tions, etc., or it may remain merely as a brown pigmen- 
tation. Distribution upon the more or less exposed surfaces 
of the body is constant. 
Many physicians in the South depend upon changes in the 
disposition of the patient for the first signs of pellagra. 
Usually the temperament is altered, periods of depression 
develop and even a state resembling early paranoia or a 
manic depressive psychosis may supervene. 
Dr. W. F. Wittwer, who has worked with the disease in 
New Mexico, finds mild digestive disturbances, with pain 
in the epigastrium, to be the initial symptom. He has also 
found a peculiar lack of elasticity in the subcutaneous 
tissue characterizing many cases. 
Another sign that is commonly present in a later stage of 
the disease is the denuded, ulcerated and painful condition 
of the mucous membrane lining the mouth and pharynx. 
Prevention.—A well balanced diet, containing the essen- 
tial vitamins, will prevent pellagra and cure an incipient 
case. Milk alone, if used to the amount of 2 or 3 quarts a 
day, will suffice for this purpose. Some southern health 
officers are inducing families liable to pellagra to keep a 
cow and to use the milk freely. This plan has met with 
apparent success in several localities. 
Public health nurses can do much to educate the families 
whom they visit in the proper selection of food. Often the 
only reason for falling into a onesided diet is ignorance, 
usually coupled with slovenliness or poverty. Patience 
and persistence will overcome these tendencies, sometimes 
aided by outside assistance in cases where poverty is a 
factor. 
Mortality.—Pellagra has a case fatality rate of about 5%. 
Goldberger estimates, from deaths reported in the southern PLAGUE 
263 
states, that there were probably 100,000 cases of the 
disease in the United States in 1916. The tendency has 
been toward a gradual increase, which should be combated 
by every live health officer through education of the public 
in the matter of a balanced dietary. 
23. PLAGUE 
Under date of June 22, 1920, the Surgeon General of the 
United States Public Health Service sent out a statement 
to the press of the country which had this to say in part: 
“Entirely in accordance with the forecasts made by the Public Health 
Service over a year ago, bubonic plague has made its appearance in the 
United States. At the moment, foci of the infection are known to exist at 
New Orleans, Penascola and Galveston, and in Tampico and Vera Cruz, 
Mexico. In Vera Cruz, the disease appears to have assumed the propor- 
tions of an epidemic.” 
Shortly afterward, he could have added a few other port 
cities to the list of foci in the United States. 
This offers an excellent illustration of what was said in 
connection with cholera, that these diseases are a constant 
menace to the world, held back only by the unceasing vigi- 
lance of our national public health authorities. Within 
recent years the disease appeared on our Pacific coast, 
but was stamped out by a concerted attack upon the carriers 
of infection. 
In man, and perhaps the lower animals, plague assumes 
three forms; bubonic, pneumonic and septicemic. The 
first is most common, while the second may appear in 
circumscribed outbreaks. Usually the septicemic form 
is a terminal condition of the other two, although it may 
be the primary form of the infection in occasional cases. 
Infective Agent.—During an epidemic of the disease in 
China, Kitasato and Yersin simultaneously discovered a 
bacillus which was later proved to be the specific organism 
and was named Bacillus pestis. It is closely related in 264 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
character to the infective agents of swine plague and 
chicken cholera. In the bubonic type of the disease bacilli 
are found abundantly in the lymphatic glands affected. 
Pneumonic cases show these organisms in the sputum and 
they may be found in the blood of patients suffering with 
the septicemic form of infection. The bacillus does not live 
outside of a living body, excepting on culture media in the 
laboratory. Drying, light and heat kill it easily. 
Immunity.—One attack of the disease usually protects 
for life. A vaccine has been developed within recent years 
that gives a fair degree of immunity for a short while. If 
it does not avert the disease entirely, it usually modifies 
the course quite favorably. A serum has also been used as 
a therapeutic agent, but nothing is said of its prophylactic 
value. 
Modes of Transmission.—Plague is primarily a disease 
of rats and of other rodents. Its propagation among 
human beings depends almost entirely upon this fact, for 
an attack upon these animals, if properly conducted, will 
cut short an epidemic. The infection may exist for a long 
period among rats, before it makes its appearance in persons 
living in the same locality. And between epidemics, in 
those places where plague prevails, the rats may always be 
found to be infected. Many of them carry a chronic 
form of the disease, thus continuing as foci of infection for 
other rodents and for man, over a considerable period. 
The agent by which plague is transmitted to man is 
the rat flea. Fortunately, these vermin do not feed on man 
by preference, but only occasionally, else we should have 
even more devastating epidemics than are usual. In rat 
infested premises, however, the flea does travel from rat to 
man, as well as from rat to rat, carrying in its digestive tract 
many thousands of bacilli. The latter have a peculiar 
ability to penetrate the skin through minute abrasions, so PLAGUE 
265 
that infection through the flea bite is readily accomplished. 
The organisms are either deposited on the skin with the 
flea’s dejecta, or introduced directly by regurgitation at the 
time of biting. 
As has been said, other rodents may acquire the disease 
and transmit it to man in the same way. At the pres- 
ent time, plague is prevalent among ground squirrels in 
California and may make its appearance in man if conditions 
favoring the invasion of human habitations by these rodents 
should arise. 
Pneumonic plague is usually a complication of the 
bubonic type, in the first cases appearing, but is then 
disseminated by sputum spray. In this form it is highly 
contagious. 
However, the British Plague Commission studied the 
disease in India and concluded, after exhaustive investi- 
gation, that not more than 3% of all cases could possibly 
be attributed to contact. Single cases of bubonic plague 
often occur in a family, although all members have been 
living in the closest contact and amid most insanitary 
conditions. When several cases occur in a family, they are 
usually simultaneous, denoting infection at the same time. 
Thus it will be seen that transmission depends upon the 
rat. The same may be said of control measures. 
Diagnosis.—In the midst of an epidemic diagnosis of 
plague is made without difficulty. However, the health 
officer must be prepared to diagnose the first cases, and to 
do so successfully he will have to resort to the laboratory. 
Fluid withdrawn from an inflamed lymph node, by 
puncture, will usually be found to be crowded with plague 
bacilli. Direct smears from suppurating buboes will also 
show the organisms. Post mortem they can be found in the 
heart’s blood and spleen quite readily. If doubt exists, 
material from these sources should be inoculated into rats 266 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
or guinea pigs, where the disease will make its appearance 
quickly. An especially useful method of inoculation is to 
shave the abdomen of a guinea pig with a dull instrument 
and rub the suspected material, or culture, upon the abraded 
skin. As was said, B. pestis penetrates an abraded skin 
with ease, while other organisms do not pass so readily. 
Thus a differential filter is produced, which will distinguish 
plague in a few days. 
Direct smears of sputum in the pneumonic type will 
reveal immense numbers of plague bacilli. Sputum may 
also be used in the same manner as other pathological 
material mentioned, for the purpose of laboratory diagnosis. 
In any suspected outbreak of plague we are particularly 
interested in detecting the disease among rodents. It is 
necessary, then, to have an idea of the post mortem appear- 
ance of lesions produced in these animals. Those who have 
had wide experience of this sort give the following features 
as of especial importance, in the order named. 
1. A diffuse pink color of the subcutaneous tissues, due 
to hemorrhagic infiltration. 
2. Enlargement of the superficial lymphatic nodes, with 
surrounding edema and hemorrhagic areas. 
3. Liver mottled, with hemorrhagic and yellow, necrotic 
areas. 
4. Excess fluid in the peritoneal cavity. 
5. In chronic cases, abscesses of lymphatic glands and 
purulent or caseous foci in the spleen. 
Methods of Control.—Plague control is synonymous 
with rat extermination. This is self evident, but its 
practical application must be supervised by persons 
trained in the best methods of rat catching and rat proofing. 
The rodent itself is trapped, poisoned or shot. All food is 
protected from rats, thus driving them to seek nourishment 
away from dwellings. Buildings of every description are 267 
PLAGUE 
made proof against the ingress of rats, depriving them of 
shelter and nesting places and forcing them to go elsewhere. 
By applying these principles a community may be 
thoroughly rid of rats in a short while, but there can be 
no relaxation of watchfulness, if it is to remain free of the 
pest. Deratting is not only good sanitation, but good 
business, for the economic loss caused by the depredations 
of these animals amounts to an enormous sum, estimated 
for the United States to be $180,000,000 annually. 
When expert advice cannot be had, the best method of 
rat extermination is by poisoning. Because of the econo- 
mic, as well as sanitary, significance of the rat, the following- 
directions for preparing poison, as given in a recent bulletin 
of the Public Health Service, are reproduced in full: 
“In exterminating rats, either by poisoning or by trap- 
ping, it is important to bear in mind that success depends 
largely on the degree to which the removal of other foods 
makes' the poisoned bait or the bait in the traps attractive 
to the rat. A variety of poisons may be used, barium 
carbonate, phosphorus, arsenic, and others, but even with 
an efficient poison, failure often results through lack of 
attention to details. 
How to Use Barium Carbonate 
I. KIND OF BAIT. Three or more kinds of bait should be used. Each 
must be mixed separately with barium carbonate. One kind of bait 
from each of the following classes should be used: 
1. Meat or other animal substance; such as Hamburg steak, sausage, 
canned salmon, eggs or oysters. 
2. Fresh fruit or vegetable food; such as cantaloupe, tomatoes, green 
corn, baked sweet potatoes, bananas, etc. 
3. Miscellaneous foods, milk or cheese, peanut butter, bread, cake, 
cereals (raw or cooked). 
II. HOW TO MIX. The barium carbonate must be thoroughly mixed 
with the bait, so that the rats cannot eat the smallest portion of the 
bait without getting some of the barium carbonate. In the case of 
such substance as Hamburg steak, cheese, etc., use one part of barium 
carbonate to 4 parts of bait. Mix thoroughly with a spoon. 268 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Substances which cannot be thoroughly mixed with the barium 
carbonate as just described (for example, cantaloupe, tomatoes, etc.) 
should be cut into small pieces and thoroughly covered with the 
barium carbonate, and then worked in with a knife. 
HI. HOW TO SET POISON. The three kinds of bait, prepared as above, 
should be divided into small portions about a teaspoonful each and 
placed freely about premises, alternating baits 1, 2, 3. It should be 
set at short intervals, not over ten or fifteen feet. DO NOT MIX 
THE DIFFERENT KINDS OF BAIT WITH EACH OTHER. 
IV. GENERAL INSTRUCTIONS. The morning after baiting, look for 
dead rats and remove them. Take up baits. Examine these so as 
to see which have attracted most rats. If any kind of bait has not 
been touched, use a different bait instead of this. Fresh bait should 
be used each night. 
V. HOW OFTEN TO BAIT. Bait every night, as long as rats continue to 
eat bait. 
VI. CAPTION. Keep fowls, dogs, cats, etc., away from bait. 
ANTIDOTE. An emetic, followed by Rochelle or Epsom salts.” 
For the eradication of other rodents, special measures may 
be necessary, such as the use of poison gas in their burrows. 
The exhaust gases from gasoline engines have been success- 
fully used for this purpose. 
In a case of the pneumonic form of plague, every care 
must be taken to prevent the diffusion of sputum spray from 
the patient. Also, articles soiled with his sputum must 
be thoroughly sterilized. Concurrent disinfection of dis- 
charges from lesions should be practiced in all types of the 
disease. 
At the first appearance of suspected cases, the entire 
population should be protected by means of a vaccine, as 
far as practicable. 
Mortality.—One million persons died of plague during 
1907 in India alone. Thirty to 90% of bubonic, and 90% 
of pneumonic cases die. The ‘ ‘ Black Death ” of Europe, in 
the 14th century, has been the symbol of devastating epi- 
demics for 600 years. Even today, 500,000 persons die each 
year of plague in India. These figures speak for them- 
selves as to the mortality of the disease. PNEUMONIA 
269 
For the health officers of port cities the warning cannot 
be made too urgent, to be on the alert for plague. It is 
nearer to us than it has been for many years. 
24. PNEUMONIA 
The term pneumonia is generally used to cover a number 
of acute inflammatory processes in the lungs arising from 
different causes. The ones that primarily interest us here, 
however, are acute lobar and broncho-pneumonia produced 
by the pneumococcus. It has been only in recent years 
that this disease has been recognized as communicable and 
coming within the purview of the health officer by reason 
of that fact. Indeed, it should be a universal requirement 
that pneumonia cases be isolated. When we consider that 
about 10% of all deaths are due to this one disease alone, it 
looms large as a public health problem. Like influenza, 
pandemics of pneumonia sweep over the world at varying 
intervals, their appearance assuming a certain periodicity 
and rising to a high peak occasionally. While cases are not 
present in great numbers at any one time, the disease is 
always more or less prevalent, particularly in winter, and 
with its high mortality has a pronounced influence upon the 
death rate. 
Infective Agent.—In 1880 Sternberg discovered the 
pneumococcus and published a description of it the fol- 
lowing year, just three months after Pasteur had announcd 
a similar finding. It was several years later, however, 
before the organism was recognized as being a causative 
agent in pneumonia. Today, we can identify four classes 
of pneumococci, usually designated as Types I, II, III and 
IV. Of the relative prevalence and virulence of these 
types, Rosenau has the following to say: 
“Group I is found in about 33 per cent, of all cases of 
pneumonia, and has a mortality of about 25 to 30% of 
cases caused by it. ... 270 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
11 Group 7/ is indistinguishable from Group I save by the 
agglutination reaction. It is found in about 33% of all 
cases of pneumonia, and has a mortality of about 25 to 
30%. ... A number of atypical members of this group 
are now classified as sub-group II. 
“ Group III is the pneumococcus mucosus, formerly 
confused with the streptococcus mucosus. . . . This type 
is the cause of about 10 to 15% of all pneumonia, and is 
fatal in about 50 to 60 % of cases. . . . 
“Group IV comprises all pneumococci that do not belong 
to groups I, II and III. The strains in this group are not 
specific. . . . These organisms have a comparatively 
low virulence, causing about 20 % of cases. . . . ” 
It will be seen, then, that the more virulent types cause 
about 80 % of all cases. 
Immunity.—There is a relative natural immunity to the 
disease which apparently, may be lowered at times by 
various causes, such as other pathological processes and lack 
of proper hygiene. Between the sixth and fifteenth years 
a higher relative immunity exists, while both extremes of life 
are especially susceptible. Unlike the majority of diseases 
of this sort, one attack of pneumonia seems to predispose 
to subsequent recurrences. It has been rather definitely 
demonstrated that a brief, artificial immunity to Types I 
and II, lasting about six months, can be produced by the 
use of killed suspensions of the corresponding bacteria. 
Such bacterins were used with favorable results in the 
Army. 
Modes of Transmission.—Many healthy persons con- 
stantly harbor pneumococci of Type IV, which is least 
virulent, and may infect others. The other three types 
are usually found only in the mouths of persons who have 
been in recent contact with cases of corresponding types, 
or who are recovering from attacks of the disease. There PNEUMONIA 
271 
is, therefore, a serious carrier condition constantly present 
in all communities, although each individual carrier retains 
the organisms for only a short time. Transference of the 
virus is accomplished by means of droplets of saliva pro- 
jected into the environment of patient or carrier, as well as 
by hands, utensils, towels, etc., soiled with the secretions 
of the mouth. 
Diagnosis.—Determination of the type of infection, by 
laboratory examination of the sputum, is gaining in favor 
with clinicians. It should be more widely practiced, as 
by that means the proper serum for therapeutic purposes 
can often be selected. 
It is necessary here only to mention that pneumonia may 
occasionally be confused with pulmonary tuberculosis, 
actinomycosis, pulmonary anthrax, pneumonic plague and 
with invasion of the lungs by intestinal parasites. 
Methods of Control.—The patient sick with the disease 
should be isolated and his sputum promptly destroyed, 
while articles soiled with it should be burned or disinfected. 
Visiting in the sick room should be discouraged by all 
means. Indeed it would not seem to be too rigorous to 
require that the house be placarded as an educational 
measure, in the interest of the public health. Control of 
the carrier is beyond the limitations of our administrative 
machinery, at the present time. On the other hand, no 
immunizing agent of universal application has been found. 
The health officer, then, must devote himself to inculcating 
principles of correct hygiene in the minds of the public. 
Since overcrowded living quarters are conducive to out- 
breaks of pneumonia, he should be particularly interested 
in improving the housing conditions of his community. 
And he should advise the repeated use of antipneumococcus 
vaccine in order to reduce the incidence of such cases as are 
amenable to this prophylactic measure. 272 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Mortality.—The mortality resulting from pneumonia has 
already been touched upon. After the fifteenth year it 
rises slowly but steadily until, of persons sixty-five or over, 
the death rate per 100,000 is over 700. Much can be done 
to reduce this frightful loss by the application of immune 
sera, in cases produced by the first two types of the organism, 
and by vaccination. But in spite of every effort, pneumonia 
will remain a tremendous factor in our mortality statistics, 
for some time to come. 
As a complication of some other acute infectious diseases, 
broncho-pneumonia is the principal cause of death. This 
is notably true of measles. Any steps, therefore, which 
reduce the prevalence of such diseases will produce a 
marked diminution of the pneumonia death rate. Fur- 
thermore, the health officer can do much to encourage 
proper care of infectious disease cases, once they have 
developed and thereby help to prevent the appearance of a 
complicating pneumonia. 
25. POLIOMYELITIS (INFANTILE PARALYSIS) 
Before influenza took foremost place upon the stage of 
human attention, poliomyelitis had long occupied such a 
position by reason of the fact that numerous outbreaks, 
some of them running into thousands of cases, had occurred 
in various parts of the country, within a comparatively 
short space of time. The disease struck fear to the heart 
of high and low alike, for none was spared, no precaution 
seemed to avail for its prevention, little was known of 
its causative agent and the resulting deformities, in those 
who escaped death, were pitiful in the extreme. For several 
years no widespread epidemic has occurred, but we have 
with us constantly a residue of sporadic cases which may, at 
any time, give rise to another devastating outbreak. 
The disease, therefore, deserves careful attention by sani- POLIOMYELITIS 
273 
tarians, for nothing like an adequate solution of its problem 
has been reached. 
Infective Agent.—It was only in 1913 that Flexner and 
Noguchi demonstrated the organism of poliomyelitis in 
culture for the first time. Highly refined technique is 
required for its cultivation, as it is extremely delicate and 
will not grow on ordinary laboratory media. Its identity 
has been established by repeatedly reproducing the symp- 
toms and pathology of poliomyelitis in monkeys by means 
of inoculation of cultures into the central nervous system 
or blood, as well as by introduction into the stomach and 
by swabbing on the mucous membrane of the nose and 
throat. 
Incubation Period.—Extensive studies, carried on in 
New York, of the epidemic occurring there in 1916 indicate 
that the incubation period is under one week. Animal 
inculations do not furnish exact data on the subject. 
Occasionally a case develops long after exposure, the 
explanation for which seems to be that the victim first 
acquired a carrier condition from which the active case 
later arose, as is sometimes true for diphtheria. 
Immunity.—Susceptibility is quite strikingly high in 
the age group 1 to 4 years, falling rapidly until the case inci- 
dence reaches 16.1 per 100,000 in the age group 15 to 19 
years, and is practically nil at 45. Only one person in 
every hundred within families having a case of poliomyeli- 
tis develops a case from exposure in the household, while 
in scarlet fever the ratio is 1 to 10 and in diphtheria 1 to 
16, probably indicating that immunity is quite general in 
the population. In this connection it is interesting to 
note one of the conclusions reached by Lavinder, Freeman 
and Frost in their exhaustive study of the New York 
epidemic, “That an epidemic of one to three recognized 
cases per thousand, or even less, immunizes the general 274 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
population to such an extent that the epidemic declines 
spontaneously, due to the exhaustion or thinning out of 
infectable material.” 
Modes of Transmission.—Many theories have been 
advanced in the last few years to explain the manner by 
which poliomyelitis gains access to the human nervous 
system. The one which appeared to be supported by the 
greatest weight of evidence was that of transmission by the 
biting stable fly. Careful epidemiological investigations 
and laboratory experimentation have not borne out this 
theory. Another theory, that was held for a time, was 
that domestic animals or rats were the source, or the vectors, 
of infection. However, paralytic diseases of animals have 
been demonstrated to be in no wise connected with polio- 
myelitis and it has been impossible to transmit the disease 
to any animal, save the monkey, with resulting symptoms 
comparable to those in the human being. Furthermore, 
no evidence has been adduced to indicate that animals 
might be passive carriers of the infection. 
Invariably, the virus has been found in the secretions 
of the nose and throat of both infected human beings and 
of monkeys. In the case of the latter this is true, even 
when the organisms are injected directly into the brain 
or spinal canal, or when introduced into the stomach 
through a tube. It would appear, therefore, that the virus 
is eliminated through the secretions of the upper respira- 
tory tract. From this, it would be reasonable to suppose 
that the disease is acquired by droplet infection. In a 
few cases, monkeys have been infected by rubbing the 
virus on the unbroken mucous membrane of the nose and 
throat. 
Sight must not be lost of the fact that there are more 
mild, unrecognized cases of the disease than of the paralytic 
or non-paralytic forms. Such cases, together with healthy POLIOMYELITIS 
275 
carriers, doubtless explain the spread of infection that 
otherwise would often be without solution. In a small 
proportion of cases, infection can be traced directly to a 
patient sick with the disease. 
Diagnosis.—As indicated by the foregoing, diagnosis 
of the mild case is of really greater importance, from the 
public health standpoint, than the recognition of frank 
cases. The latter present the usual stigmata, while the 
former range from a mere digestive disturbance of two or 
three days’ duration, to more or less severe prostration 
and even meningeal involvement, clearing up rapidly, 
in a few days, without sequelae. A complete discussion 
of diagnosis is given by P. A. Surg. J. P. Leake in Reprint 
No. 431 of the Public Health Service Reports. This 
paper is well worth careful study. In it the author points 
out that, in the presence of frank cases, “the combination 
of fever, vomiting, constipation, drowsiness, and irrita- 
bility, especially when combined with headache, a transient 
flushing of the face, abnormal sweating, or retention of 
urine, is enough to make a tentative diagnosis of polio- 
myelitis.” It is hardly necessary to say that a careful 
watch should be kept for any appearance of paralytic 
symptoms and the affected parts be given absolute rest 
and support in the natural position, in order to obviate 
as much deformity as possible. 
Lumbar puncture offers confirmatory evidence, but must 
be done carefully and with as little injury to the membranes 
of the cord as possible. “Increased pressure, with a 
clear, or nearly clear, fluid containing no organisms, a 
cell count over 10 per c.c., and increased albumin and 
globulin, when found, are of great diagnostic value.” 
(Leake.) 
Methods of Control.—The patient, whether presenting a 
marked case of infection or only suspicious symptoms, 276 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
should be well isolated and should be protected from flies, 
as these may possibly act as passive carriers in occasional 
cases. Discharges from the nose, throat, bowels and kid- 
neys should be thoroughly sterilized, preferably by burning 
or boiling. The nurse must cleanse her hands thoroughly 
after handling the patient or anything that has been in 
contact with him. 
Since the carrier condition becomes quite general in an 
outbreak, it is manifestly impossible to control all such 
persons, or even to discover them. However, it is reason- 
able to quarantine, for two weeks from last exposure, all 
children who have been in contact with a case, and to 
forbid all adults, who are contacts, mingling in any way 
with minors. Where school medical inspection is available, 
all school children who are absent from school during an 
outbreak should be visited in their homes and careful 
observation of their symptoms maintained, in order to 
discover any mild cases. When medical inspection cannot 
be had the appearance of a case in school would warrant 
closing for two weeks and quarantining of all the children 
exposed. 
Mortality.—As a general rule, the mortality of polio- 
myelitis is rather low, but in widespread outbreaks it may 
rise much higher. An average for practical purposes 
is a case fatality rate of 20 per cent. Treatment with 
immune serum offers the only hope we have, at present, of 
reducing mortality, and this is often uncertain in its action. 
However, the deformities resulting from paralysis of 
varying degrees are an extremely serious feature of the 
disease, aside from mortality, for they render many victims 
dependent for life upon charity, or unable to gain an 
adequate livelihood. Every physician treating a case of 
poliomyelitis should familiarize himself with the advances 
that have been made in relieving somewhat the disabilities RABIES 
277 
produced by paralysis, as well as the best methods for 
preventing deformity, so far as that is possible. 
We should note two features of the disease that may have 
a lively interest for us in the near future. There appears 
to be a periodicity of about six years in the development of 
epidemics, and once started, an epidemic is more severe 
in rural than in urban communities. Bearing these 
points in mind and remembering that we always have a 
few cases present in every state, it is possible that we shall 
see an outbreak of some proportion in 1922 or 1923, or 
six years from the time of the last greatest prevalence of 
the disease, in 1916. In fact, as this is being written, 
in the latter part of 1922, there is a notable increase of 
cases in many parts of the country. 
26. RABIES 
While rabies produces only a small number of deaths, 
the manner of death makes it particularly terrible. Coupled 
with this is the fact that it is entirely preventable, which 
gives it especial interest to the health officer. Like anthrax, 
rabies is primarily prevalent among lower animals, and is 
acquired from them by man only through accident. All 
animals are susceptible in varying degrees to the infection 
and even birds may acquire the disease. Its geographical 
distribution is worldwide, with certain exceptions that 
will be mentioned later. 
Infective Agent.—Noguchi claims to have grown the 
fine granular bodies supposed to be the infective agent, 
and to have produced genuine rabies with his cultures 
after passing them through many transfers. So far, 
this has been the only work that would appear to demon- 
strate the specific organism. It is supposed that the 
“ Negri bodies’7 are the causal agent and Park and Williams 
believe that these bodies are protozoan in nature. Others 278 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
incline to the view that they merely represent degenerative 
processes in the nerve cells. Whatever the facts may 
prove to be, it has been demonstrated that the true Negri 
body is specifically characteristic of rabies. 
Incubation Period.—The incubation period of the disease 
varies more widely in man than in the lower animals. 
The latter usually develop symptoms within 6 to 21 days 
after infection, depending upon the activity of the virus, 
site of inoculation and susceptibility. In man the period 
depends also upon these factors, but may vary from 14 
days to 7 months, both figures being the extremes. Twenty- 
one to 60 days may be given as the average for man, with 
the tendency toward the higher figure. 
Immunity.—Only about 16 per cent, of persons bitten 
by demonstrably rabid animals develop the disease. How- 
ever, part of this immunity is only apparent. The 
virus is carried in the biting animal’s saliva and this may 
be removed, if the animal bites through the clothing, 
leaving not enough on the teeth to produce infection. 
Even so, it would appear that natural immunity does 
exist to a certain extent. This seems to be influenced 
somewhat by the location of the wound and its size. 
Modes of Transmission.—With few exceptions, rabies is 
transmitted by the bite of an infected animal. In those 
exceptional cases, in which it develops without the victim 
being bitten, we find that a broken skin surface has received 
saliva from such an animal. Evidently the saliva of rabid 
animals is the vector of infection. This has been demon- 
strated beyond doubt by animal experimentation. Other 
secretions of the body, as well as many of the tissues, carry 
the virus, but cases of infection have never been traced to 
these sources. 
The infective agent travels to the central nervous system 
by way of those nerves in the immediate vicinity of the RABIES 
279 
wound. The richer the nerve supply, the sooner will 
infection reach the brain and cord. In the case of facial 
wounds, rapid extension takes place, while a bite in the 
lumbar region will often prove harmless. 
It is an interesting fact that the bites of various animals 
differ in their virulence, probably due to the kind of wound 
inflicted. A rabid wolf produces the most serious wound, 
while that of the cat comes next and of the dog third. 
Horses and mules can produce the disease, but the form of 
their teeth prevents deep penetration of the tissues. It 
should be remembered that a rabid dog will occasionally 
travel great distances, before death overtakes him, and that 
he may thus spread infection broadcast among other animals. 
Diagnosis.—The health officer should be informed of the 
diagnosis of rabies in animals, particularly the dog. Briefly, 
the symptoms may be given as follows: 
1. Prodromal Stage.—The animals appear listless and sick 
for one or two days. 
2. Excited or Convulsive Stage.—This is the stage which 
is popularly supposed to be typical of rabies. The animal’s 
nature is changed. He may snap and bite at those with 
whom he has formerly been quite gentle. Or he may run 
about attacking every object in his way. At this time he 
may refuse water, not from fear of it, but because the act of 
swallowing produces a painful spasm of the throat. These 
two stages are often quite brief or apparently absent. 
3. Paralytic Stage.—A progressive paralysis begins with 
the hind extremities and advances until the entire mus- 
culature is involved. Death may supervene at any time 
during these three stages, but is usually preceded by 
paralysis. 
But reliance must not be placed solely upon clinical 
symptoms for diagnosis. When an animal has developed 
pronounced symptoms, it should be killed and the head sent 280 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
to a reliable laboratory, packed in ice. Here the brain will 
be removed and sections or smears examined for Negri 
bodies. If these are not found, animal inoculations will be 
made as a final and practically infallible test. However, the 
animal must not be killed until actual symptoms have 
become well marked, or the laboratory tests may be difficult 
or a failure. Practically all dogs will show symptoms of 
rabies. within 15 days, so that time is still given for pre- 
ventive treatment after a diagnosis has been made. 
In man the disease is diagnosed on the history of exposure 
to infection and the various stages above outlined. Rabid 
persons, however, do not attempt to bite others, as a rule. 
Neither do they “bark like a dog,’ ’ mew like a cat, nor bray like 
a mule, depending upon the kind of animal that bites them. 
Methods of Control.—Practically all of our rabies cases 
arise from the bites of rabid dogs. These animals often 
travel far, as was noted, while other infected animals do 
not. The problem of control, then, has largely to do with 
the proper handling of dogs. 
In England the effect of a strict muzzling lawT, combined 
with a six month’s quarantine of all imported dogs, has 
been quite striking in its reduction of rabies cases. After 
bringing the number of human cases down to six, in the 
year 1892, muzzling was relaxed, and by 1895,37 persons had 
died of rabies in the three years, while the number of rabid 
animals found in the last year alone amounted to 672. 
Muzzling was again enforced and cases among men and 
animals dropped to zero. Norway, Sweden and Denmark 
have not had any rabies in 50 years, due to strict quarantine 
on imported dogs. By the same means, Australia has the 
enviable record of never having had a case. 
Two years of muzzling or leashing all dogs, with the 
impounding of those allowed at large, would wipe out 
rabies entirely in the large centers. RABIES 
281 
A recent development in the prevention of rabies is the 
prophylactic inoculation of all dogs. Some health depart- 
ments have adopted this as an alternative measure for 
muzzling. One to three doses of the canine vaccine are used. 
This method has already proved its worth in Japan and is 
gaining favor in this country. It seems to be logical and 
will relieve the health and police departments of much 
worry, if universally applied. 
All cases occurring in animals should be reported to the 
health department. 
As a means of preventing the disease in human beings, 
prophylactic treatment should be freely available. Pasteur 
is perhaps better known for having devised this method than 
for any other work he did. While it is not necessary to 
detail the technique of preparing and administering the virus, 
a brief mention may be made of it. Virus from a rabid 
animal is introduced into a rabbit and then transferred to a 
series of them until it has attained high virulence for other 
animals. The virus is then termed “ fixed. ” Spinal cords 
from such animals are treated by one of several methods 
until dry and containing a stable amount of virus. These 
cords can be preserved for a short while, at low tempera- 
tures, and can be shipped in glycerine for use at distant 
points. The use of this treatment reduces the mortality 
to a negligible quantity, if effected in time. But the person 
exposed to rabies should be treated as soon as a diagnosis is 
made in the animal. If severe lacerations have been pro- 
duced, or the animal responsible for a wound cannot be 
found, and a reasonable suspicion of rabies exists, immediate 
treatment should be instituted. While occasional compli- 
cations have resulted from the treatment, such instances 
have been so rare that treatment should not be delayed or 
deferred for fear of such eventuality. 282 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Mortality.—The human mortality from rabies is 100 %. 
No further comment is needed for the thoughtful health 
officer. 
27. ROCKY MOUNTAIN SPOTTED FEVER 
Rocky Mountain, or tick, fever has its greatest incidence 
in Montana and through the northwestern region of the 
United States, but also extends in a milder form through 
Colorado into northern New Mexico. It is a disease of 
thickly wooded regions that tends to disappear as the 
timber and undergrowth are cleared. 
Infective Agent.—The specific organism of the disease 
has not been isolated, although some observers believe they 
have succeeded in associating an amoeba-like parasite with 
the infection. The virus is not filterable, but is transferable 
in the blood of a patient sick with the disease. 
Incubation Period.—The period of incubation is not 
known. 
Immunity.—There is no natural immunity to infection, 
but an attack of the disease is probably protective. This is 
true, at least, for guinea pigs. 
Modes of Transmission.—Ricketts definitely demon- 
strated that the infective agent is transferred by the bite 
of a tick, dermacenter reticulatus. It was also shown that 
the female tick could transmit the parasite to her young, 
which would then become infective for human beings. It 
is probable that the disease is kept alive for long periods in 
this manner. 
Diagnosis.—Fever gradually rises, in one infected, much 
as with typhoid. By the end of the fifth day it attains a 
high point, which is maintained for another week, when it 
gradually declines in those who are to recover. On about 
the fifth day of the disease, an exanthem appears which 
many have described as like that of typhus fever. The SCABIES 
283 
eruption tends to confluence, with petechiae and an icteroid 
discoloration of the skin. Occasionally gangrene of isolated 
portions* of the skin develops. Edema of the face and 
gradual increase in the pulse rate are other features. Guinea 
pig inoculation with blood from suspected cases will give 
positive results, if the disease is present, and will distin- 
guish it from typhus. 
Methods of Control.—The patient himself is not danger- 
ous to those about him, but can infect ticks, if they should 
gain access to his bed. 
Clearing and burning over of land covered with brush 
will serve to eradicate the tick. It is also reported, from 
regions where the disease has existed, that grazing sheep 
upon tick infested land is effective in destroying them, 
due to the fact that the male tick is not able to reach the 
female, through the sheep’s wool, and there is a resulting 
diminution of succeeding generations. They tend thus 
to disappear gradually. Tick infested domestic animals 
should be regularly dipped. 
In regions where the disease is endemic, persons going 
into wooded sections should protect themselves from tick 
bites by the use of high boots and heavy clothing. 
Mortality.—In Montana the disease has had a mortality 
of 70 to 80 %. Other localities report rates as low as 2 or 
3 %. It is, however, a dangerous disease and should be 
considered in making a differential diagnosis of eruptive 
fevers occurring in regions where it may be found. 
28. SCABIES 
Scabies, or the common itch, is gradually becoming more 
rare as the lessons of hygiene are learned and practiced more 
widely. 
Infective Agent.—The animal parasite responsible for 
the symptoms is the sarcoptes scabiei var. hominis. That 284 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
“the female of the species is more deadly than the male” 
is entirely true of scabies, for the female alone produces the 
lesions. The parasite burrows its way into the upper layers 
of the skin, depositing from 10 to 25 eggs as she advances, 
until she finally dies in the rete mucosum. In the course of 
8 to 10 days the eggs hatch out and each new female starts 
a burrow of her own. This process continues indefinitely, 
if treatment is not had. 
Incubation Period.—A parasite begins to burrow into 
the skin as soon as deposited upon it from some other source. 
Once eggs have been laid a period of 10 to 12 days elapses 
before the next generation has hatched and is capable of 
further reproduction. This might be considered the incu- 
bation period for further infection. 
Immunity.—All persons appear to be susceptible to the 
parasite. 
Modes of Transmission.—Any contact, direct or indirect, 
that will implant a living parasite upon a non-infested 
person can conceivably disseminate the condition. Practi- 
cally, careful personal cleanliness will usually destroy any 
parasites thus received, before they have been able to 
establish themselves. However, even the most cleanly 
person occasionally falls a victim. Sleeping in a bed with an 
infested person is one of the commonest means of acquiring 
parasites. Constant contact within a family will also 
spread the disease, through other means. 
Diagnosis.—The part most frequently chosen for initial 
attack by the parasite is the hand, especially between the 
fingers. The patient then transfers organisms to other 
parts of his body, usually the shoulders, legs, waistline and 
scrotum. Burrows on the inner side of the fingers, with 
excoriations of the skin, and burrows on the other parts of 
the body mentioned, serve to indicate the nature of the 
condition at once. Itching, worse at night, is always SCARLET FEVER 
285 
present to a marked degree. History of other persons, 
closely associated with the patient, who present similar 
symptoms, helps to confirm diagnosis. 
Methods of Control.—An infested person should be 
treated as thoroughly and promptly as possible. While 
undergoing treatment, he should sleep alone and his 
bedding and underclothing should be boiled at frequent 
intervals to kill the parasites. Children bearing the infes- 
tation should be excluded from school until free from the 
organisms. Visiting nurses can do much to eradicate such 
conditions by educating their charges in hygiene and 
sanitation. 
Mortality.—There is no mortality from scabies. 
29. SCARLET FEVER 
Because of the multiplicity of its possible complications 
and sequelae, as well as the frequent severity of the disease 
itself, scarlet fever has always been one of the most dreaded 
diseases of childhood. Aside from a mortality ranging 
between 4 per cent, and 30 per cent , it often leaves in its 
wake lifelong disablement of greater or less severity. For 
many years, the tendency has prevailed to reserve the term 
‘ ‘ scarlet fever ’ ’ for those cases which are well marked, while 
“scarlatina” has been applied to the more mild forms. 
This is an error that should be corrected, for the two 
terms are exactly synonymous, the former being the English 
form of the Latin “febris scarlatina.” 
Infective Agent.—A great mass of research work has 
been done to determine the causative agent of scarlet fever, 
but success has not yet been achieved. That it is a micro- 
organism cannot be doubted, for the disease behaves in 
all respects as do those of a definite microbial origin. How- 
ever, nearly all cases present a severe streptococcus invasion 
of all parts of the body, to which the grave symptoms and 286 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
dangerous complications are usually due. Many experi- 
ments have demonstrated the infective virus in the secre- 
tions of the nose and throat, in material from the tonsils 
and in the exudates of various lesions. Its infectivity 
increases to some extent, during the development of the 
exanthem, and may persist in some patients well through 
convalescence, or even after apparently complete recovery. 
This complicates the problem of control to some extent. 
Incubation Period.—Incubation is comparatively brief, 
usually being given as from one to seven days. In experi- 
mental inoculations it was rather constantly three to four 
days in duration. 
Immunity.—Very young infants are generally immune. 
From then until the age of about ten, children are quite 
susceptible, but not to the extent noted in measles, smallpox 
and chickenpox. As age advances susceptibility decreases 
proportionately. However, immunity to the disease is 
variable in the individual, for a child may escape infection at 
one time only to succumb at another. One attack usually 
protects for life. 
Some work has been done with streptococcus vaccine 
that would warrant further investigation of this agent as a 
prophylactic. A few observers have also noted an apparent 
immunity conferred by diphtheria toxin-antitoxin. 
Modes of Transmission.—Experimental inoculation of 
the secretions from the nose and throat has produced the 
disease. It is evident, then, that the saliva is infective 
both as droplets in expired air and when freshly deposited 
upon various articles. Exudates from the lesions have 
also been shown to be a source of infection. The former 
is usually most infective at the height of the exanthem, 
while the latter may retain the virus for an indefinite period. 
Scarlet fever is constantly prevalent in larger communities, 
but develops sporadically in smaller ones. Often it is quite SCARLET FEVER 
287 
difficult or impossible to trace the origin of an outbreak. 
It is possible that carriers exist to a certain extent at all 
times, but it is probable that the many mild cases, some 
presenting practically no symptoms, contribute most largely 
to the dissemination of the disease. Where strenuous 
efforts have been made to detect and isolate these atypical, 
or “ missed, ” cases epidemics have subsided with surprising 
abruptness. 
Milk-borne outbreaks of scarlet fever are rather frequent, 
traceable, without difficulty as a rule, to some person 
engaged in the preparation or sale of the milk. These 
outbreaks are usually explosive in character and may be of 
considerable extent. One such was found to originate with 
a milker who had a suppurating lesion of the finger, follow- 
ing an attack of scarlet fever. 
That the desquamated epithelium of a case is capable of 
propagating the disease has long been taught, until it 
has become thoroughly interwoven with sanitary practice. 
We know now, however, that such is not a fact, for repeated 
attempts to reproduce scarlet fever with the scales have 
failed entirely. Modern sanitary practice ignores the scales 
in determining the period of isolation for the patient. 
Diagnosis.—The symptomatology of scarlet fever is 
quite familiar to all physicians and the frank case is not 
likely to be erroneously diagnosed. There are, on the 
other hand, many mild cases of the disease that are called 
by almost any name but the correct one. “Stomach rash” 
is an old favorite of this class. Much of this confusion 
could be saved by (1) the taking of a careful history in which 
would usually be found an exposure to some other child 
with a similar condition; by (2) noting more or less severe 
prodromal symptoms developing suddenly; by (3) a thorough 
examination of the entire body of the patient for the 
presence of the typical rash and sore throat, and, (4) later, 288 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
by observing desquamation, which may vary from a fine, 
branny scale to great patches of integument. Another 
point of value to those who have access to a microscope is 
the fact that there is more or less leucocytosis in this disease 
as contrasted with measles or German measles, in which an 
opposite condition of the blood prevails. 
Occasionally a case of scarlet fever is diagnosed as 
diphtheria, from a heavy deposition of exudate in the 
throat. Such an error could hardly occur if a complete 
examination of the patient’s body were made. In such 
cases there is also a more profound prostration than is 
found in the early stages of diphtheria. 
Another disease, not commonly seen, that resembles 
scarlet fever quite closely, is the so-called scarlatiniform 
erythema. The two are identical in many respects, but 
the latter condition does not present the marked systemic 
disturbance that would be expected in a case of scarlet 
fever exhibiting an equal amount of rash. This form of 
erythema is also characterized by regular, periodic recur- 
rences, often for a period of many years. 
As a general rule, and certainly if scarlet fever is present 
in the community, any case presenting a history of sore 
throat, with fever, possibly vomiting, and a diffuse rash, 
should be suspected of being scarlet fever, no matter how 
mild these symptoms, and a provisional isolation should be 
maintained. It is best to err on the side of safety to the 
public. Many epidemics have been caused by neglect of 
this important principle. 
Methods of Control.—The patient should be isolated 
promptly and held in isolation as long as there is a path- 
ologic discharge from any body cavity, or an exudate from 
any lesion. Concurrent disinfection must be practiced 
rigorously, as practically all secretions and exudates are 
infective, so far as we know. The nurse must cleanse her SCARLET FEVER 
289 
hands thoroughly, after handling the patient or articles 
that the patient has recently used. 
Since the incubation period is short, it is necessary to 
quarantine contacts for only seven days from date of last 
exposure. This restriction applies to children and to 
adults whose occupations bring them into contact with 
children. 
When an outbreak of scarlet fever occurs in a community, 
all school children should be examined every morning, 
during its continuance, and any child with even slightly 
suspicious symptoms should be promptly excluded. If 
competent inspection is not obtainable, it would be better 
to close schools, for one week, in small communities, 
requiring the teacher to examine all children carefully for 
signs of sore throat, rash or desquamation, upon their 
return, and to send those presenting such conditions to the 
health officer for further investigation. Absentees, upon 
re-opening, should be carefully investigated. 
It is hardly necessary to say that no one who has the 
disease, or who is convalescing from it, or who is nursing a 
case of it, should be permitted to handle milk or other foods 
intended for public distribution. 
The health officer should make an energetic search for 
the source of an outbreak of scarlet fever, always bearing 
in mind the two factors of mild, missed cases and of an 
infected milk supply. He should also educate the teachers 
within his jurisdiction to a recognition of the early, suspi- 
cious symptoms, such as feverishness, sore throat, vomiting 
and the general catarrhal manifestations. 
Mortality.—Outbreaks of scarlet fever vary considerably 
in their virulence. The milder forms have no mortality, 
while others run as high as 30% of all cases. The disease 
is predominantly a streptococcal infection, with all of the 
complications and sequelae characteristic of such a process. 290 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Almost any part of the body may suffer from a secondary 
invasion by the streptococcus and, often, with rapidly fatal 
results. The kidneys invariably show a greater or less 
degree of injury and the complicating nephritis is one of 
the principal causes of death. Every physician in atten- 
dance upon even the mildest cases of scarlet fever should 
insist upon absolute rest in bed for at least two weeks, 
as a safeguard against this eventuality. Furthermore, 
parents should be educated to protect their children from 
exposure to others presenting catarrhal symptoms or other 
signs of illness. Until we know definitely the causal agent 
and the methods of its control, no rational means of 
avoiding exposure should be overlooked. 
30. SEPTIC SORE THROAT 
In septic sore throat we have succeeded in separating 
out a distinct disease entity from the great mass of strepto- 
coccal infections, of which we know very little. Erysip- 
elas, puerperal septicemia, certain forms of pneumonia 
and some cases of cellulitis are among the other principal 
infections of this class. Little was known of epidemic 
streptococcus sore throat until very recent years, when it 
was studied at the time of severe outbreaks in Boston, 
Baltimore, Michigan towns and a few other localities. 
These investigations demonstrated the fact that this was 
a throat affection having a specific origin and symptom- 
atology readily distinguished from either diphtheria or 
ordinary tonsilitis. 
Infective Agent.—“Streptococcus” is the family name 
for a large group of organisms that look alike under the 
microscope, but which may be divided into at least three 
fairly well defined classes on the basis of their hemolysing 
properties. It is to one of these alone that most of the 
severe infections, such as the disease we are discussing, SEPTIC SORE THROAT 
291 
are due. This coccus has hemolysing powers and produces 
a profound intoxication, to which most of the serious 
manifestations of the disease may be ascribed. 
Incubation Period.—Little is known of the time required 
for incubation, but it is thought to be quite brief, in fact, 
only a day or two. 
Immunity.—Much confusion exists upon the question of 
immunity to streptococcal invasion. On the one hand, 
persons who have had attacks of erysipelas seem to be more 
susceptible to recurrences and there is a report of this 
disease having been produced ten times in one individual 
by inoculations for the relief of inoperable cancer. On 
the other hand, quite encouraging reports have been 
made upon the use of immune sera for the treatment of 
streptococcal infections and upon prophylactic vaccination. 
Until our knowledge of the various strains of the coccus 
is more definite, little can be expected in the way of artificial 
immunization. 
Modes of Infection.—In the disease under consideration 
the infection is primarily one of the throat and the organisms 
are found there in enormous numbers. That they should 
be transferred in the secretions of the mouth seems obvious. 
Sputum spray, articles soiled with saliva, the hands of the 
sick, of carriers and of the nurse, and all direct or indirect 
contact should be suspected. 
We do know, however, that the common mode of spread 
in epidemic outbreaks is through contaminated milk. 
This has been demonstrated by careful epidemiological 
studies of the outbreaks mentioned in the introduction to 
this section. Simon, in his work on Human Infection 
Carriers, says that every such outbreak has been traced 
to a milk supply. But, with the exception of one case, it 
has not been possible to identify the person responsible. 
A carrier has been suspected and, indeed, persons suffering 292 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
with the infection have been found upon the dairies invol- 
ved, but whether they were the primary source, or victims 
of the hypothetical carrier, could not be demonstrated. 
It was at first supposed that garget in the cow was 
responsible for the disease in man. This has now been 
demonstrated to be not the case at all, since the bovine 
streptococcus is practically inocuous to man, as likewise the 
human form for the cow. But it has been shown experi- 
mentally that the human type of the organism does invade 
the cow’s udder and there proliferate, without producing 
any apparent inflammatory process.1 It is, therefore, 
conceivable that a cow so infected by the hands of the 
milker might spread disease for a considerable period. 
And it is a fact that outbreaks of the sore throat have 
persisted over many weeks, in some instances. To com- 
plete the evidence against the milk, streptococci indentical 
with those of the disease prevailing have been found in 
milk supplied to those who were infected. 
In the population at large, persons are found in great 
numbers who harbor streptococci in their throats, either 
intermittently or continuously. Some of the cocci so 
found are of the more virulent type. This would suggest a 
carrier condition more or less constantly present. 
Diagnosis.—The outstanding feature of septic sore 
throat is the profound prostration produced at the very 
outset of the attack. This should serve to warn the 
physician of an extremely toxic invasion and aid in dis- 
tinguishing it from diphtheria. In both diseases we see a 
pseudomembrane on the throat which has no distinguishing 
marks in either case. But the toxemia appearing at the 
commencement of symptoms is suggestive. A throat 
swab should always be taken and cultured. A direct 
1 An exception to this has recently been noted. See Jour. Ain. Med. 
Ass’n. for June 16,1923. SEPTIC SORE THROAT 
293 
smear from the swab will usually reveal the streptococci 
in great numbers, sometimes in apparently pure culture. 
Implanted upon Loeffler’s blood serum medium, the organ- 
isms can be distinguished by growth and by stained smears 
in twelve hours. The laboratory test is useful in dis- 
tinguishing streptococcic throat infections from diphtheria. 
Care should be exercised to differentiate septic sore throat 
from tonsilitis and from scarlet fever. 
Methods of Control.—The patient must be isolated and 
the discharge from his mouth and nose destroyed. Articles 
soiled with these discharges must be well disinfected. 
The nurse should observe scrupulous cleanliness of the 
hands at all times. 
Until we know more of the modes of transmission and the 
nature of the infective agent, little can be done to control 
contacts upon a rational basis. 
At the first appearance of several cases, the health officer 
should look carefully into the milk supply. If a large 
proportion of the patients receive their milk from a common 
source, this should at once be suspected. In view of what 
we already know, it would be reasonable to insist upon 
pasteurization of this milk before it is allowed on the 
market. The throats of all persons who are connected 
with its production and sale should be cultured repeatedly 
and those who show a marked streptococcal flora should 
be excluded from the dairy. In some cases, it would be 
practicable to examine the milk of each separate cow 
bacteriologically in order to discover whether a cow is the 
source of infection. 
Finally, it would do no harm to offer prophylactic 
vaccination with a good, polyvalent vaccine, to all who 
desire it. 
Mortality.—The percentage of cases which terminate 
fatally is not high, running to about four per cent, in the 294 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
more virulent outbreaks. There is a secondary death rate, 
however, which swells this figure; how much, we do not 
know. Complications and sequelae may be severe and 
such affections as endocarditis and nephritis are not at 
all uncommon. The disease is sufficiently debilitating and 
its complications dangerous enough to warrant every effort 
being made to control it. 
31. SMALLPOX 
One hundred and fourteen years ago, Thomas Jefferson 
wrote to Jenner, the originator of smallpox vaccination as 
practiced today, “future nations will know by history 
only that the loathsome smallpox has existed and by you 
has been extirpated.” In the two years just passed, 
an alarming increase of smallpox has been noted in many 
parts of the country. Recently, outbreaks of the most 
malignant form have appeared in several communities. 
It is a growing menace to our people. That such should 
be the case is all the more deplorable when we consider 
that it is the most easily controlled of the whole group of 
transmissible diseases. Nor is smallpox always the benign 
affection to which we have become accustomed in recent 
years, as evidenced by the fact that a careful estimate 
attributes to this disease alone 60,000,000 deaths, during 
the eighteenth century. Three and a half million lives 
are said to have been sacrificed to it in a short period 
after the Spanish invasion of Mexico. And within twenty- 
five years this country has seen circumscribed outbreaks 
of high mortality. The mild form prevalent today made 
its appearance in the southern part of the United States 
about 1896. Because of its supposed origin in that island, 
it was called “Cuban Itch” and this term is sometimes 
applied to it even yet. It was also given the name “vario- 
loid,” which is quite indifferently used, but, according to SMALLPOX 
295 
the best usage, this term should be reserved for those 
vaccinated cases which run an atypical course. The fact 
should not be forgotten that both varioloid and the less 
virulent type of smallpox are one and the same with true 
smallpox, or “variola vera,” and capable of producing 
serious cases in the unvaccinated. For a masterly descrip- 
tion of the disease, deserving a place among medical 
classics, the reader is urged to study carefully Schamberg’s 
description in his textbook on “Diseases of the Skin and 
Eruptive Fevers.” 
Infective Agent.—Considering our fund of knowledge 
relating to smallpox, it is quite remarkable that the specific 
organism causing it has never been identified. Of late, 
some work has been done that rather points to a proto- 
zoon as the infective agent. 
Incubation Period.—Eight to 14 days will cover the 
incubation period of typical smallpox, or “variola vera,” 
while it sometimes extends to 21 days in the mild type. 
Immunity.—All persons in all age periods are exquisitely 
susceptible. One attack usually protects for life, but there 
are recorded cases of one to four recurrences. 
VACCINATION WITH COWPOX VIRUS WILL 
CONFER IMMUNITY FOR A CONSIDERABLE 
PERIOD. Our general freedom from violent and fatal out- 
breaks of the disease is due to this fact alone. Two 
successful vaccinations will confer immunity for life, upon 
the majority of persons. An attack of the disease in a 
person so vaccinated, if it occurs at all, will be of the 
mildest form. 
The word “successful” is used advisedly, for many 
attempts at vaccination are not successful, although 
they may appear to be so to the uninformed. The proper 
procedure in vaccinating and the resulting reaction are 
described in the following outline form. 296 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
METHODS OF VACCINATING 
1. Be sure that the virus is fresh. It deteriorates rapidly 
at ordinary room temperature and, for that reason, should 
be kept in the ice box. Stocks should be frequently 
renewed. 
2. Select a convenient place upon the subject’s body, 
preferably on the left arm or just below the scapula on the 
back, or on the thigh. 
3. Cleanse the skin thoroughly and dry with alcohol or 
ether, if desired. Do not use antiseptics, as they will 
destroy the virus. 
4. Place two or three drops of the virus upon points on 
the skin about one inch apart. Multiple applications of 
vaccine produce a much higher percentage of “takes” 
than does one alone. 
5. Pass a needle through the flame of a match, or alcohol 
lamp, and prick the skin lightly, through the drops of 
virus, making about twelve punctures in each drop, but 
not drawing blood. This procedure may be varied, if 
one wishes, by first making one or two small scratches on 
the skin and then rubbing in a drop of virus on each scratch. 
Some prefer to use the point of a bistoury, or scalpel, 
instead of the needle, but the latter is more convenient 
because of the ease of sterilization. THE SMALLER 
THE AREA OF INOCULATION, THE LESS CHANCE 
THERE IS OF INFECTION, SORE ARMS OR DIS- 
FIGURING SCARS. 
6. Do not put any dressing over the vaccination. Its 
application only does harm by favoring the growth of 
bacteria. A square of clean gauze may be pinned to the 
inside of the sleeve to prevent sticking. This warning 
applies to the entire course of the eruption. If the site 
of inoculation is not more than four millimeters in diameter, SMALLPOX 
297 
the vaccination will develop a distinct, circumscribed 
pustule, with a firm pellicle, which is tough and not easily 
broken. 
A very successful method of scarification, which is the 
most rapid of all, especially in vaccinating schools or other 
large groups, is to use a small chisel, similar to a No. 4 
dental chisel, with a 4 mm. blade. This may be sterilized 
in a flame, and the scarification made by rotating the chisel 
on the skin. Only the epidermis should be removed, enough 
to expose the derma, but not enough to draw blood. 
The resulting scar of vaccination is quite characteristic. 
It is at first red, gradually fading to white. The surface is 
pitted with many fine indentations, which should be 
distinguished from the seams and ridges resulting from the 
ulcerations which may be present if secondary infection has 
extensively invaded the area. 
If the subject has been previously vaccinated, and still 
maintains a partial immunity, the course of a second vacci- 
nation may be somewhat accelerated, the whole occurring 
within a period of eight or nine days, with less systemic 
reaction, and with a very slight resulting scar. Such a 
partial vaccination is termed a “ vaccinoid.” Again, a 
second vaccination done within a comparatively brief 
period after a previous vaccinia, or in persons with a well- 
developed immunity, usually presents an immediate, or 
“immunity” reaction, with papulation on the first or 
second day, a distinct areola, and a prompt subsidence, 
without passing through the other typical stages. Both the 
vaccinoid and the immunity reaction, if definitely observed, 
should be considered to be successful vaccinations. 
In closing the discussion of vaccination, a word should be 
said as to the alleged dangers of the procedure. Undoubt- 
edly, in times past, when virus fresh from a case, or from 
an animal, was used, without the care in preparation given 298 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
it today, some untoward complications developed. How- 
ever, accidents due to infected virus are practically unknown 
at present, since all virus is carefully controlled by the U. S. 
Public Health Service, before being placed upon the market. 
The writers have, bewteen them, personally performed or 
supervised over 25,000 vaccinations and have never seen a 
complication more serious than a sore arm of a few days’ 
duration. During the past few years, many stories of 
amputations, etc., necessitated by vaccination, have been 
traced to the original subjects of the various tales and, in 
every case, these rumors were found to be absolutely untrue. 
Experience has shown that practically all the unpleasant 
occurrences in vaccination may be avoided, if the following 
three simple rules are observed: 
1. Make the area of scarification as SMALL AS 
POSSIBLE. 
2. Do not use any shield, nor any dressing that will 
prevent free access of air to the vaccination. 
3. Handle the vaccination with scrupulous cleanliness. 
Modes of Transmission.—Personal contact is undoubt- 
edly the principal factor in the spread of smallpox. Often, 
in the mild type, as the eruption appears, the patient feels 
well enough to get up and be about and so has the opportu- 
nity to spread infection widely. Occasionally, the prodro- 
mal symptoms are so mild as to permit the patient to be 
about until the rash appears, thus exposing many to 
infection. 
There can be no question, also, of the infectivity of the 
products of inflammation in the skin, which appear to carry 
the unidentified virus. The exudate, either moist or dry, 
is infective for quite a period, as are also the scabs. Articles 
soiled with the discharge and with secretions of the mouth 
could transfer infection to others, and it could be carried 
on -the feet and proboscis of a fly. It has been demonstrated SMALLPOX 
299 
that “air borne” infection, as commonly interpreted, has 
no part in the spread of the disease. The case in an early 
stage, coming into contact with unvaccinated persons, is 
the principal factor in the dissemination of smallpox. 
Diagnosis.—Because of the frequency with which 
chickenpox and smallpox are confused, it is important 
that the health officer be well grounded in their differential 
features. There is no single pathognomonic sign to be 
found in every case, but a diagnosis must be based upon a 
number of details. Those listed below may all be present 
to a marked degree, or they may be modified more or less, 
or some of them will be lacking entirely. But enough will 
be presented by every case to make a definite determination 
possible, when the picture is studied in its entirety. 
1. The prodromal symptoms are usually severe, especially 
the headache, pain in the back and fever. They may be 
out of all proportion to the ensuing eruption. These 
symptoms continue for three days, at least. Following this 
there is a distinct remission of the prodrome just prior to 
commencement of the eruption. 
2. On the fourth or fifth day from the commencement of 
symptoms, the eruption makes its appearance on the face 
and wrists as a macule, developing in twenty four hours into 
a papule with a hard, “shotty” feel to it. There is a con- 
tinuing formation of new lesions, for a day, upon the parts 
first attacked. Meanwhile other portions of the body are 
undergoing the same process, but with the lesions a little 
behind the eruption at the site of first appearance. A point 
of particular significance is the fact that the EXPOSED 
parts of the body, together with the legs and feet, present 
by far the greatest number of lesions. This is the opposite 
condition to that found in chickenpox, where the TRUNK 
and face are more markedly affected than the forearms or 
lower portions of the legs. To observe the distribution of 300 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
the eruption, it is urged that the whole body be seen at one 
time. In doubtful cases, the number of lesions in equal 
areas of skin, on different principal parts of the body, should 
be counted. A rather characteristic feature of smallpox 
is the appearance of a varied amount of eruption in the palms 
of the hands and the soles of the feet. Because of the thick 
epidermis these lesions do not develop in the usual manner 
and they persist for a long period after all others have 
healed, leaving a dark, mahogany-red spot which is definitely 
diagnostic. It should also be noted that in any given area of 
the skin all of the lesions are of practically the same age, while 
those of chickenpox may be of all ages,from macule to scab. 
3. True umbilication is seen only in smallpox. It is a 
depression of irregular shape in the center of the vesicle and 
is not due to partial collapse of the vesicle, as may be 
observed in chickenpox. 
4. The covering of the vesicle is tough and cannot be 
ruptured easily with the finger nail, while that of chickenpox 
has a frail, easily broken surface. 
5. A feature of considerable significance in smallpox is 
the duration of the eruptive stage. From the appearance 
of the macule to the commencement of desiccation, a 
period of at least eleven days intervenes. 
6. When all signs fail, a final resort may be had to 
vaccination of the patient as a test. If there is an immunity 
reaction the presence of smallpox may be safely assumed, 
unless the person has recently been vaccinated. 
To sum up, then, observe the following principal diag- 
nostic points: 
1. A rather severe prodromal period. 
2. A distinct remission in these symptoms, just prior to 
the appearance of the rash. 
3. Distribution of the rash. “The broad features of 
distribution are that the rash prefers the upper half of the SMALLPOX 
301 
body to the lower, that it is a rash of the face and arms 
rather than of the trunk and legs, that it is a rash of the 
distal ends of the limbs rather than of the proximal, of the 
back of the trunk rather than of the front, of the extensor 
surfaces rather than of the flexor, and that it is a rash which 
shuns the most pronounced flexures.” (Ricketts & Byle.) 
4. Lesions in the same stage on any given area of skin. 
Methods of Control.—Smallpox is the most easily con- 
trolled of the acute infectious diseases and the foremost 
method is contained in one word—VACCINATE! A 
vaccinated population need have no fear of smallpox, nor 
endure a tedious and expensive period of quarantine. 
Vaccinate every school child upon entering the primary 
grade, again in five years, and finally in high school. 
Vaccinate every person who may have come even remotely 
into contact with a case of smallpox. In a generation the 
disease will have become a curiosity in a community so 
protected. This is no idle theory, but has been demon- 
strated on a national scale in Germany, for many years. 
There are advanced communities in the United States that 
have not seen a case in five years. We have frequently 
observed that schools in which the children were fully 
protected by vaccination have continued to operate, with- 
out interruption, while smallpox was extensively prevalent 
in the community, and not a case has developed among the 
children successfully vaccinated. Note, however, that the 
vaccination must really be a successful “take” and not a 
perfunctory scratch on the arm. 
It is surely reasonable to allow absolute freedom of move- 
ment to any person, recently in contact with smallpox, 
who will submit to successful vaccination. Aside from the 
nurse, there need be no restriction placed upon other mem- 
bers of a household wherein smallpox exists, provided this 
precaution is observed and the patient is well isolated. And 302 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
even a nurse, who has been well protected by vaccination 
and who takes the necessary precautions as to personal 
cleanliness, need not be confined to the premises. 
Isolation and concurrent disinfection of the most rigorous 
sort must be practiced in the case of a patient sick with 
smallpox. Secretions of the mouth and nose, exudates 
from the lesions, and scabs that have been cast off, are all 
infective. They must be destroyed at once and completely, 
by burning, if practicable, or by boiling and the use of 
antiseptics. In this connection it should be noted that 
phenol preparations, in the strength ordinarily used, do not 
exert a destructive action upon the virus. Boiling water 
should be the disinfectant of choice wherever at all appli- 
cable. Screening of the patient against flies is also of 
considerable importance. 
Those who have come into contact with smallpox must 
be quarantined until successfully vaccinated, or, refusing 
that, for a period of 15 to 21 days. 
Mortality.—The disease has been extremely fatal, in 
times past, and there is every reason to believe that this 
type of infection may make its appearance again. In 
fact, several outbreaks of extremely fatal smallpox occurred 
during the winter of 1921-22, in some of the western and 
mid-western states. The mortality ran as high as one out 
of every three cases, in a few communities. While the 
present mild type of smallpox has practically no mortality, 
it occasionally gives rise to a fatal case. Rosenau gives 
the case fatality of this type as 0.5 per cent. 
32. TAPEWORM INFESTATIONS 
A number of tapeworms are found in nature which more 
or less frequently infest man. ThejnosHmportant of these 
are the species derived from hogs, cattle, fish and dogs. TAPEWORM INFESTATIONS 
303 
Infective Agents.—The pork tapeworm is Taenia solium, 
the adult being found in man, and the larval form, known 
as Cystercercus cellulosae, being found in pork (commonly 
called “Pork measle”). The beef tapeworm is Taenia 
saginata, the larval form being found in cattle, and termed 
Cystercercus bovis (commonly called the beef “measle”). 
From dogs we have Taenia echinococcus, the larval form of 
which is found in man, and is known as an echinococcus, or 
hydatid cyst. Occasionally infestations with another dog 
tapeworm, the Dipylidium caninum, are reported. The 
most frequent tapeworm found in man is a small form 
known as Hymenolepsis nana. 
There are two types of tapeworm infestation in man; 
that with the adult worm, which occurs in the intestinal 
tract, and that with the larval form, which may occur in 
various body organs in the form of cysts. The adult 
worms are flattened, elongated, segmented worms, the 
different species of which may vary in length from a few 
millimeters to several feet. The mature segments are bi- 
sexual, and discharge large numbers of eggs, which develop 
into the larval cysts when ingested by suitable hosts. 
Incubation Period.—The periods of incubation of the 
diseases due to tapeworms are indefinite, and depend 
partly on the time required for the development of the 
parasite, and partly upon the extent and locus of infestation. 
Immunity.—There is no known natural immunity to 
tapeworm disease. 
Modes of Transmission.—Larval cysts of the pork, beef 
and fish tapeworm are ingested by man when uncooked, or 
incompletely cooked, flesh of such infested animals is 
eaten. Larvae or eggs of dog tapeworms may be received 
by"direct contact with the animal. 
Diagnosis.—Parasites infesting the intestinal tract throw 
off segments and eggs in the stools. Macroscopic and 304 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
microscopic examination of the latter will disclose the kind 
of worm present. Cystercercus and echinococcus diseases 
are often difficult to diagnose, and may be confused with 
abscesses of the organ or region affected. Often an increased 
eosinophilia is suggestive. Their final diagnosis usually 
depends upon finding the larval cyst in the lesion. 
Methods of Control.—Thorough cooking of meats and 
fish will destroy the larval forms of several of the species 
infesting man. It should be noted that large pieces of 
meat may require as much as an hour to become heated 
throughout. The offal accumulating at abbatoirs should 
not be fed to hogs or dogs without thorough cooking. Pet 
dogs should be treated to rid them of intestinal parasites. 
Mortality.—Rarely does a tapeworm (adult) kill by its 
presence alone. Occasionally children may suffer from 
intestinal obstruction due to this cause. On the other hand, 
farval cyst infestation of a vital organ may be quickly 
latal. Intestinal parasites all produce more or less debility 
and secondary anaemia, which renders the victim more 
liable to serious results from other infections. 
33. TETANUS 
While not a communicable disease, in the usual sense of 
that term, tetanus has a public health significance as a 
cause of mortality that is largely preventable. During 
the late war, it assumed considerable importance and its 
prophylaxis was given especial attention. 
Infective Agent.—B. tetani is found almost universally 
in soil that has been mixed with manure of horses and 
cattle. It is a spore forming organism and for this reason 
can persist for a long period of time under conditions that 
would be fatal to other forms of bacteria. The spores 
resist drying, but not direct sunlight. Symptoms in TETANUS 
305 
tetanus are the result of the powerful toxin formed by 
B. tetani. It is of interest to note that the bacillus is found 
in the intestinal tracts of animals and that this fact may 
account for its occasional presence in surgical “catgut.” 
Incubation Period.—As a rule, symptoms of tetanus 
develop in the second week after infection. Longer and 
shorter periods are sometimes noted. The infection may 
lie dormant for months in the scar of a wound, only to 
light up under the disturbing influence of an operation. 
Immunity.—Natural immunity in man appears to be 
absent. Artificial immunity can be induced by the use of 
antitoxin. Five hundred to 1500 units are usually given 
for this purpose. Its routine administration to all wounded, 
during the war, proved a life saving procedure, when results 
were compared with those of former wars. 
Modes of Transmission.—Tetanus is invariably acquired 
through the introduction into the body of material carrying 
the bacilli or spores. Usually garden soil or street dust are 
the vectors of infection, finding their way into the deeper 
portions of a wound on the object that inflicts it. Improp- 
erly sterilized dressings and ligatures have carried the 
infection. Babies occasionally die of tetanus from the use 
of dirty materials for tying the cord. In Cuba this was a 
frequent cause of infant mortality until an enlightened 
government supplied the midwives with sterile ligatures. 
Occasionally, we find a case of tetanus that offers no 
evidence of its source. From our knowledge of the disease 
and from experimental work, we know that it cannot 
enter through unbroken skin. It is likely, therefore, that 
such cases are really the result of minute injuries or of 
invasion from the intestinal tract. 
Diagnosis.—Masseter spasm, followed by stiffness of the 
neck and later by convulsive seizures, are the cardinal 
symptoms of tetanus. In the early stages, a patient’s 306 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
blood serum bearing the toxin will produce tetanus in a 
mouse. Cultures from wound exudates and their inocu- 
lation into animals will also confirm diagnosis. 
Methods of Control.—One method of control is alone 
available—the early use of antitoxin. In every case pre- 
senting a wound that has been soiled by earth, or manure, 
antitoxin should be given at once and repeated at weekly 
intervals until healing is completed. Midwives must be 
taught to use sterile ligatures in tying umbilical cords. 
Toy cap pistols of the old style, a frequent source of tetanus 
infection, should be prohibited. If any operative procedure 
is to be instituted in the presence of a healed wound that 
might have received B. tetani, antitoxin administration 
should precede operation. 
Excepting the exudate of his wound, a patient suffering 
with tetanus is not dangerous to his attendants and no 
precautions are necessary, save the proper disposal of 
dressings. 
Mortality.—Untreated tetanus produces a mortality of 
about 75 per cent. This varies inversely with the length of 
incubation period and directly with the abundance of nerve 
fibres about the wound. 
Prophylactic serum has reduced mortality to the van- 
ishing point. Where symptoms have developed, it has 
also doubled the percentage of recoveries, when used 
therapeutically. 
We may say that mortality in tetanus, as in diphtheria, 
depends upon the early use of sufficient antitoxin. 
34. TRACHOMA 
“The protection of the citizen from the assaults of 
ignorance, indifference, or neglect, when they threaten 
his well-being and even his economic efficiency, is a duty TRACHOMA 
307 
which the state cannot evade and which he has a right to 
exact.” Thus is formulated the principle upon which is 
based every activity of the health officer that has to do 
with the conservation of human comfort and efficiency 
rather than the preservation of life. Those infections, 
therefore, which are likely to produce partial or total 
blindness offer a fruitful field of such activity and with one 
of them the present section deals. 
Trachoma is as old as recorded history, but it is only in 
modern times that its contagiousness has been recognized 
and intelligent efforts made to control its spread. No 
immigrant is allowed to enter this country if he presents 
evidence of being infected with the disease. Many states 
have laws or regulations looking to its control. But before 
such measures were adopted, the disease gained a foothold 
and has remained endemic, for years, in some of our more 
remote communities. 
Infective Agent.—The specific organism still remains 
unidentified, but that it exists cannot be doubted from the 
fact that the disease spreads slowly through a family or a 
group of persons who are closely associated. We do know, 
however, that the virus can be killed by heating for three 
minutes to 50 degrees C. 
Incubation Period.—The period required for incubation is 
unknown. 
Immunity.—Apparently, all persons, of all ages, are 
susceptible to infection. 
Modes of Transmission.—The discharge from infected 
eyes is contagious and can be transferred on the fingers, as 
well as by those articles that may become soiled with it, 
such as towels, wash basins, handkerchiefs, spectacles, etc. 
The common towel has been regarded as the chief offender 
in this respect, by those who have studied the disease in 
localities where it prevails. 308 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Diagnosis.—The patient usually notices first a smarting 
of the eye, as if some particle of foreign matter had gotten 
under the lid, and he generally ascribes all subsequent 
symptoms to some such cause. Very slowly the disease 
takes root in the membrane lining the lids, producing 
hard, shining, translucent, yellowish elevations that are 
about the size of an ordinary pin head. During this process 
pus exudes, gluing the eyelids together in the morning, and 
there is much inflammation of the entire conjunctiva, with 
lacrymation and photophobia, in the majority of cases. 
Constant irritation of the eyeball from the granulation 
usually produces corneal ulceration, which is the immediate 
cause of visual impairment. Remissions or intermissions 
are quite characteristic of the infection. The inflammatory 
process sometimes throws the membrane lining of the eye- 
lid into folds which may be so extensive as to obscure the 
granules. But the latter can always be found in the fold 
of membrane at the point where it meets the eyeball. 
Diagnosis rests upon a history of gradual development, with 
remissions, and upon the characteristic appearance. 
Methods of Control.—Control depends primarily upon 
proper hygiene, such as the avoidance of towels and like 
articles that are used in common, coupled with scrupulous 
cleanliness of the hands when in contact with the disease. 
Children suffering with the infection should be removed 
from school, if in the acute stage, and should not be allowed 
to attend at any time unless receiving constant and adequate 
treatment. Intelligent adults should be instructed as to the 
dangers of the disease to themselves and others. Those 
who are wilfully careless might well be isolated, if presenting 
acute symptoms. 
Common towels and other such articles as may convey 
the fresh virus should be absolutely banished from any 
civilized community. TRICHINOSIS 
309 
Where the disease has become prevalent in a community, 
free clinics for treatment should be maintained by public 
funds, both for the sake of the patient and the protection of 
the well. This is particularly necessary in the poorer 
districts because of the tedious course of treatment required 
to produce even an arrest of the disease. 
Mortality.—There is no mortality from trachoma. 
35. TRICHINOSIS 
Trichinosis is a parasitic disease common toman, smaller 
carnivorous domestic animals, and rats. The usual cycle 
is from rat to hog to rat, but the cycle may be completed in 
either hog or rat. 
Infective Agent.—The adult worm, Trichinella spiralis, 
inhabits the intestinal canal of the host, and the female 
discharges embryos into the intestinal lumen. The 
embryos penetrate the mucous membrane of the intestines 
and thereby enter the blood stream, by which they are 
carried to all parts of the body. The embryos develop 
into larval worms which, after migrations through the 
muscles and tissues, become encysted in the striated 
muscles. During migration they produce acute symptoms 
of trichinosis disease. 
Incubation Period.—Symptoms of the disease appear 
in from ten to twenty days after ingestion of infected meat. 
Immunity.—No natural immunity to Trichinella spiralis 
is known. 
Modes of Transmission.—Eating raw or incompletely 
cooked pork is the chief mode of transmission of Trichinella 
spiralis. The hog usually acquires its infestation from 
eating offal, or rats, about slaughterhouses. Rats become 
infested from eating offal, or each other. A double or 
triple cycle of hog to hog, rat to rat, or rat to hog to rat, 310 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
occurs about insanitary slaughterhouses. Infection in man 
is more or less accidental and secondary to the other 
primary cycles. 
Diagnosis.—There are two stages to the clinical mani- 
festations of trichinosis. The first coincides with the 
intestinal invasion and development of the worm, and is 
ordinarily characterized by pain and diarrhea. Secondly, 
general systemic invasion by the embryos gives rise to 
severe symptoms marked chiefly by violent muscular pains, 
local edema, and a considerable increase in eosinophile 
count. Slight infestations may give mild symptoms. 
If trichinosis is suspected, definite diagnosis may be estab- 
lished by excising a small section of muscle (usually the 
deltoid), and examining a thin section under the low power 
of the microscope. At the onset of the symptoms blood 
may be taken in 3 per cent, acetic acid, centrifuged, and 
examined for embryos. Embryos and dead males may 
be recognized in the stools during the initial intestinal 
symptoms. 
Methods of Control.—Thorough cooking of all pork 
and sausage will protect man from invasion by Trichi- 
nella spiralis. Hogs should never be fed uncooked slaugh- 
terhouse offal. Rats about slaughterhouses should be 
exterminated. Storage of pork and pork products at a 
temperature of 5 degrees Farenheit for twenty days or longer 
will kill all encysted larvae. This is probably the best 
protection available, as it avoids the possible ill effects of 
poorly cooked meat. 
Mortality.—The case fatality of trichinosis is about 
half that of typhoid fever, but may rise higher in some 
outbreaks. It would appear from dissecting room studies 
that from 1 to 2 per cent, bear evidence of having suffered 
from trichinosis at some time in life. 311 
TUBERCULOSIS 
Long before Koch announced his discovery of the 
tubercle bacillus, tuberculosis had engaged the attention 
of many sanitarians as a problem of the first magnitude. 
That it still maintains its rank is evident on every side. 
Autopsies done on 195 children, dying of various causes 
between the ages of 2 and 10 years, revealed the presence 
of tubercle bacilli, living or dead, in 60 per cent. Rosenau 
says, “The toll falls heaviest during the period of life of 
greatest usefulness—thus 30 per cent, of all deaths between 
the years of 15 and 60 are due to pulmonary tuberculosis 
alone. Naegli, from a careful examination of a large num- 
ber of bodies in Zurich, found evidence of tuberculosis in 
over 90 per cent.” Such figures merely serve to show that 
infection is well nigh universal and that the death rate 
is extremely high. 
Like syphilis, tuberculosis attacks practically every 
structure of the body; but, unlike the former, it spares the 
mental faculties, except as these may be injured by a 
meningitis. However, 70 per cent, of all tuberculosis is 
pulmonary. 
We must draw a distinction between infection with 
tuberculosis and the developed disease itself. As was said 
in the beginning, infection is nearly universal; but not all 
who are infected develop recognizable symptoms. Thus 
the duty of the health officer is twofold; to prevent infection 
as far as possible, and to reduce the incidence of disease in 
those already infected. Provision for the care of developed 
cases is an important part of his work under the first head- 
ing, aside from its social and humanitarian value. 
Infective Agent.—In 1882, Koch announced to the world 
that he had solved the question of the specific agent 
producing tuberculosis. Subsequent investigation proved 
his contention to be correct. The organism is a bacillus 
36. TUBERCULOSIS 312 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
of the acid-fast variety, enveloped in a waxy sheath, and 
does not produce spores. Sunlight and heat kill it quickly, 
while it can persist in dark, damp places for a considerable 
time. The phenol disinfectants destroy it readily, if given 
sufficient time to act. 
Besides the human variety, avian, piscine and bovine 
types of the tubercle bacillus are recognized. Fortunately, 
only the last of these is pathogenic for man, and this power 
diminishes in the ascending age groups. 
Incubation Period.—If we consider the incubation period 
as the time elapsing between infection and appearance of 
recognizable symptoms, we may say that it is measured 
in months or years for tuberculosis. It is practically 
impossible to determine the exact time of first exposure, 
but it is common experience to see children succumb 
to a tuberculous meningitis very early in life and sometimes 
within a few months following the development of an 
“open” case in a parent. On the other hand, figures such 
as those given in the opening of this chapter indicate a high 
percentage of early infection without immediate symptoms. 
The fact that children of 10 years or over give an almost 
universally positive tuberculin test seems to bear out the 
theory of early infection. If this be true, we may say that 
the incubation period is usually measured in years, or, at 
least, that there is a long period of latency preceding that of 
active development. 
Immunity.—Rosenau estimated in 1912 that 160,000 
persons died annually in the United States of tuberculosis. 
Compared with an estimated infection rate of 90 per cent., it 
is evident that a rather high degree of natural immunity 
exists among us. This resistance has been steadily increas- 
ing during the period for which we have any accurate 
statistics. In Massachusetts the death rate per 100,000 
of population had fallen steadily from 400 to 160 in the TUBERCULOSIS 
313 
period of 1850 to 1902. This selective process was at work 
prior to any concerted efforts at control, but the decline 
was slightly accelerated after discovery of the tubercle 
bacillus. 
Karl Pearson and other careful statisticians have demon- 
strated that susceptibility to tuberculosis in children bears 
the same relationship to tuberculosis in the parents as 
does eye color, color of hair, insanity, and other hereditary 
characteristics. This observation has an important bearing 
upon the question of control measures. A certain propor- 
tion of the population will inherit more or less of a tubercu- 
lous tendency, depending upon the germ-plasm which 
produces it. Regardless of environmental conditions, it 
will hand on this weakness to succeeding generations, modi- 
fied by mating. These considerations lead us into the field 
of eugenics, which is aside from the subject of this section. 
The point to consider is that a certain number of individ- 
uals will be continuously brought into the world who are 
not resistant to tuberculosis. Proper environment will 
raise the body resistance of these individuals themselves, 
in many cases to such a point that they will never develop 
the disease, or will recover from it, if attacked. We may 
conceive of a “threshold of resistance” for each individual. 
If his vigor is maintained above this point, he will success- 
fully combat infection; but lowered vitality will approach 
or fall below this threshold, when he will succumb. Even 
for the most resistant, such a point may be reached by a 
wasting disease or other catastrophe. 
It is believed that infection successfully combated confers 
a degree of acquired immunity upon the individual, based 
upon the fact that the incidence of disease diminishes after 
30 years of age. However, immunity cannot be produced 
by any artificial means at hand today. Tuberculin does 
not act in the manner of vaccines or serums, by producing 314 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
or introducing demonstrable antibodies. It does, however, 
stimulate the combative forces of the body against active 
tuberculosis, in some unexplained manner. 
Another factor affecting the acquisition of tuberculosis 
is the size and frequency of dose. A few bacteria in a fairly 
resistant person will have no effect whatever and will die 
quickly. On the other hand, a massive dose received by 
the same person may produce active disease. Again, 
small doses frequently repeated will establish a state of 
sensitization which may end in disease. All of this has 
been demonstrated in experimental animals and to some 
extent by studies of human infection. 
Immunity to tuberculosis, then, is a relative condition, 
limited by both heredity and environment. 
Modes of Transmission.—With infection widespread 
and with 70 per cent, of those having active disease throwing 
off tubercle bacilli in sputum and saliva, contact is obviously 
the principal mode of infection. Either sputum spray 
and kissing, or cups, spoons, pipes and all articles recently 
soiled with the saliva of a patient will convey fresh, virulent 
organisms to other persons. 
Far too much emphasis is laid upon dust as a conveyor of 
infection. While it is true that the tubercle bacillus can 
survive in the dry state, when protected from sunlight, the 
amount of really actively infective material that might 
be so spread is relatively minute as compared with the 
enormous amount of fresh and more highly dangerous 
matter that comes directly from the patient himself. 
Dried sputum is rather hard and becomes finely pulverized 
with difficulty so that few living bacilli could enter the 
atmospheric dust from this source. 
For the bovine type of tuberculosis the only important 
vector is cow’s milk. It is not necessary that there should 
be an infected udder, but bacteria can find their way from TUBERCULOSIS 
315 
the circulation directly into the milk without leaving any 
traces in the lacteal glandular tissue. Probably most 
bacilli enter milk through contamination from manure due 
to careless milking methods. 
There is no so-called hereditary transmission of the 
disease. Only a hereditary lack of resistance is transmitted. 
Occasionally a fetus may become infected in utero, but this 
is quite rare and is not hereditary transmission in the correct 
sense of that term. 
Diagnosis.—Only a few points need be emphasized in 
connection with diagnosis. Expert physical examination 
made at the first appearance of suspicious symptoms is the 
prime requisite. Nothing yet developed will take the 
place of that. There are, however, aids such as the roent- 
gen ray, sputum examinations and possibly the tuberculin 
test, that will be of help in some cases. Complement 
fixation gives some promise, but has not yet been fully 
recognized as a diagnostic method. 
For the sake of the patient and his associates, early 
recognition of active disease is absolutely essential. By the 
time a hemorrhage has appeared or bacilli can be found in 
the sputum, chances of recovery have diminished con- 
siderably and infective material has been spread about by 
the patient. 
Early and frequent use of the laboratory, for the exami- 
nation of sputum, should be made in all cases. Tubercle 
bacilli and elastic fibres in sputum are always important 
indications, when coupled with suspicious physical findings. 
In very young children presenting suggestive symptoms, 
the cutaneous tuberculin test may be of considerable value, 
for many in the first three or four years of life have not 
developed a positive reaction to tuberculin and will do so 
only at the time of infection. Later in life the test is of 
little value because of almost universal reaction to it. 316 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Methods of Control.—If we could prevent infective 
material from reaching any of the susceptible population, 
we should soon wipe out tuberculosis entirely. However, 
this is an ideal that we cannot hope to see attained in this 
generation, if ever. From the cradle to the grave we are 
constantly exposed to infection. Our efforts then must be 
directed toward preventing as much exposure as possible, 
which is the first of the two main lines of attack. The 
other group of control measures comprises all those that 
will tend to prevent development of diseases in persons 
infected. 
Since the patient with a discharging lesion in any part 
of his body is the chief source of infection, he must be taught 
to destory all infective material before it has had an oppor- 
tunity to reach any other person. Burning, boiling and the 
use of strong phenol solutions will accomplish this effec- 
tively. If the patient is too selfish or ignorant to observe 
such precautions, the health authorities should step in and 
isolate him. Articles used by the patient must also be 
disinfected before being used by anyone else. Common 
cups must be absolutely forbidden in all public places and 
dishes used by restaurants and soda fountains must be 
thoroughly cleaned. 
In connection with the control of the patient, tuberculosis 
sanitoria find their greatest usefulness from the public 
health standpoint. The same applies to public tuber- 
culosis clinics. 
Especial watchfulness is required over all children in the 
homes of the tuberculous. Every care should be exercised 
to destroy sputum, avoid coughing and kissing and in the 
disinfection of the patient’s eating utensils. 
An efficient local health department will be able to pre- 
vent bovine infection through the milk supply. Cows 
should be tuberculin tested twice annually and all positive TUBERCULOSIS 
317 
reactors removed from the herds. If inspection is not 
obtainable, pasteurization of the milk will destroy tubercle 
bacilli easily. 
Physicians should be educated to a realization that the 
patient need not be sent away from home in order to obtain a 
cure. We see many hundreds who have been cast adrift 
in the West, to become a menace to all with whom they come 
in contact. From the public health standpoint, it would be 
far better for such persons to remain at home under the 
control of their physicians, if they are unable or unwilling 
to employ such care away from home. This is aside from 
any consideration of benefit to the patient himself. 
We come now to the methods which may help to prevent 
development of disease in those infected. There is a certain 
type of child that has been given the name “ pretubercular, ” 
because of obvious hereditary susceptibility, poor physique, 
anemia, or for other reason. Whether exposed to tuber- 
culosis or not, such children need special attention in order 
to overcome a natural handicap as far as possible. Open- 
air schools, day and night camps, visiting nurses, free clinics, 
etc., all operate to care for children of this class. 
For the adult, education is our main reliance. Three 
things should be emphasized repeatedly and as widely as 
possible. 
1. Periodic examinations, done at least once a year, to 
determine any signs of incipient tuberculosis, as well as 
other disorders. 
2. The majority of persons do not know what to select 
in the way of nutritious food, nor how to prepare it. More 
general instruction in the fundamentals of dietetics should 
be given in our schools and through the press. Hand in 
hand with this should go a thorough training in hygiene. 
3. The principles of eugenics as applied to the selection 
of a healthy mate should become matters of everyday 318 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
knowledge. For persons of tuberculous heritage, who are 
already mated, a warning should be repeatedly given of the 
liability of their children to develop tuberculosis and ample 
advice made available as to the best methods of fortifying 
the body against such a contingency. 
Every health department should maintain a free clinic 
for the indigent tuberculous and for those who desire periodic 
examinations. Such a clinic provides a center of public 
health education that has a certain prophylactic effect, 
aside from the opportunity afforded to control the patient 
who may otherwise spread infection. Follow-up and social 
service work from such a center are also important adj uncts 
to control. 
In this connection tribute should be paid to the graet 
Association that has spent funds and energy unlimited in an 
effort to educate the public upon the important facts 
regarding tuberculosis. The fruit of its labor can be seen 
in the general enlightment upon this subject as well as in the 
many sanitoria, clinics and nursing agencies that have been 
established throughout the land. It has been an important 
factor in gaining better support for state and local health 
departments and in pointing the way to better public health 
in general. However, many functions performed by the 
National Tuberculosis Association should now be taken over 
by public agencies, for they are a part of public health 
administration that should not be left to private enterprise. 
Mortality.—As was stated earlier, there were 160,000 
estimated deaths from tuberculosis in 1912, in the United 
States. Definite figures for the registration area alone, 
for 1917, are as follows: 
Tuberculosis of the lungs 
. . . . 88,666—rate of 123.8 per 100,000 
Tuberculous meningitis 
8.0 per 100,000 
Other forms of tuberculosis 
.... 7,024—rate of 
9.8 per 100,000 
Total 
101,396—rate of 141.6 per 100,000 TYPHOID AND PARATYPHOID FEVER 
319 
From these statistics it is evident that the “great white 
plague” is no misnomer. The facts call for concerted, 
continuous action, especially along the indicated lines of 
education until future generations have bred a race that 
can withstand the heaviest onslaughts of tuberculosis. 
37. TYPHOID AND PARATYPHOID FEVER 
Because of their practical identity in sanitary features, 
the two diseases forming the subject matter of this chapter 
have been grouped together for consideration. Typhoid 
fever will be taken as the type, with occasional references to 
differences between it and the paratyphoid fever, types A 
and B. 
For several decades, typhoid fever engaged the attention 
of clinicians, bacteriologists and sanitarians to a degree 
probably unequalled by any other disease and with a result- 
ing literature of formidable proportions. Such concen- 
tration of effort has had a stimulating reaction upon both 
bacteriology and sanitary engineering which has lead to the 
opening up of many important lines of investigation closely 
allied to the control of typhoid fever. The subject affords 
an excellent illustration of what was said in the introductory 
chapter and of the application of the modified “Whipple’s 
Figure” to a concrete case. It emphasizes especially 
well the duties of the attending physician as distinguished 
from those of the health officer, at the same time demon- 
strating the necessity for the cooperation of these two in 
safeguarding the community. 
The name of the disease gives a hint of its history, for 
it was confused with typhus fever for many generations, 
and, when finally distinguished from the latter infection, 
was called typhus-like, or typhoid fever. Unfortunately, 
some physicians still fail to make this distinction in report- 
ing their cases. Other names have been given it, such as 320 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
“enteric fever,” but typhoid has come to be generally 
accepted as the proper term. 
In 1910, one person in every 400 of the population 
in the United States had typhoid fever. Scarcely a single 
community of 1,000 persons, or over, escaped some infec- 
tion. Since then conditions have been improving rapidly, 
but are far from what should be expected. A comparison 
of certain American and European cities for the year 1910 
shows that there was an excess of 18 deaths, per 100,000 
of population, from typhoid fever in the American cities, 
all of which might have been prevented by the application 
of principles that were well understood abroad. Today, 
the typhoid fever death rate in many of our cities is quite as 
low as any in the world. But most of our smaller towns 
and rural communities still leave much to be desired in 
this respect. 
Considering these facts, we are forced to agree with Prof. 
William T. Sedgwick, who said, “The experience of various 
communities, some large and some small, in first extermi- 
nating and then for the most part keeping off the disease, has 
demonstrated the possibility of its control. It is therefore 
impossible to avoid the conclusion that communities in 
which typhoid fever abounds are either ignorant or careless; 
and ignorance and carelessness are the ear marks of a defec- 
tive civilization. ” 
Infective Agent.—In 1880 Eberth and Koch simul- 
taneously observed the typhoid bacillus in specimens of 
tissue from typhoid cases. Gaffky succeeded in isolating it 
in pure culture, four years later, offering at that time satis- 
factory evidence of its identity. 
Unfortunately laboratory animals are not readily infected 
with B. typhosus in the same manner that it is acquired by 
man. Injected into the blood of such animals it gives rise 
to immune substances and to pathological processes that TYPHOID AND PARATYPHOID FEVER 
321 
are quite similar to human reactions. We do have good 
evidence of the specificity of the bacillus, however, through 
its constant presence in undoubted cases of clinical typhoid 
fever, as well as from the accidental ingestion of cultures by 
laboratory workers, with subsequent development of typical 
symptoms. The specific agglutination reaction (Widal) 
is also confirmatory. 
The organism is essentially a human parasite and finds 
few environments outside of the body favorable to its 
multiplication. The principal exception to this rule is 
milk, in which the bacillus proliferates rapidly until over- 
come by the lactic acid organisms. Water is frequently a 
vector of typhoid bacilli, but there is no evidence that they 
ordinarily multiply in it; rather, they tend to die off in 
great numbers, leaving only a few of the most resistant for 
any length of time. Many factors affect their longevity 
in water, such as rate of flow, sedimentation, aeration, etc. 
These aspects of the subject were discussed in former 
chapters. An interesting fact of some importance is that 
the bacillus does not find sewage as favorable a medium 
as water, for its continued existence. 
While heavy soil pollution with typhoid-bearing feces 
might result in the contamination of vegetables, the infective 
material would have to be quite fresh and the vegetables 
used promptly in the raw state to produce infection. The 
soil is a generally unfavorable medium for the bacillus, 
although not always so. 
A temperature of 80° C. kills B. typhosus in one minute. 
This has an important bearing upon pasteurization of milk 
supplies. The organism is also killed by drying and by 
sunlight in a few hours, while the disinfectants commonly 
used inhibit or destroy it easily. Freezing, while prevent- 
ing growth and killing a large percentage of the organisms, 
does not destroy all. One famous outbreak of the disease 322 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
was traced to a patient’s feces that had been thrown out on 
the ground during freezing weather and had been washed 
into a stream during the spring thaw. 
Incubation Period.—Two weeks is usually given as the 
average period of incubation in typhoid fever, but it may 
vary from one to four weeks. There seem to be some 
indications that persons may occasionally carry the organ- 
isms for months before manifesting signs of disease. 
Immunity.—While the figures on age distribution would 
indicate on their face that early middle life was the period 
of highest incidence this is probably an erroneous impres- 
sion due to failure to recognize typhoid fever in children. 
In fact, until recently, it was taught that children rarely 
had the disease, while today we are receiving reports of an 
increasingly large proportion of such cases. The decrease 
in incidence as we ascend in the age scale is probably 
due to a constant reduction of susceptible material. No 
doubt a very small proportion of the population is naturally 
immune. 
An attack of the disease usually confers immunity for life, 
but this is not constantly true. 
A high degree of immunity can be produced by means of 
prophylactic “ vaccine.” To this agent we owe the remark- 
able record of our Army. In 1910 the ratio of cases to 
1,000 of mean strength was 2.43. During September 1911 
compulsory vaccination against typhoid was introduced and 
the ratio fell to 0.85 for that year. In 1914 the figure was 
0.07. Despite the stress of the war just ended, only about 
750 cases developed in our entire Army, part of which was 
due to faulty technic and failure to give the complete pro- 
phylactic treatment. 
Immunity by vaccination continues for about two years, 
if a preparation of good quality is used. Recently, a so- 
called lipo-vaccine has been tried, but it has failed, so far, TYPHOID AND PARATYPHOID FEVER 
323 
to give adequate protection. It is advisable to use a 
combined vaccine, containing typhoid and paratyphoid 
A and B, for one does not protect against the other. 
Modes of Transmission.—While the typhoid bacillus 
may reach its human host by means of water, milk, food, 
flies and direct contact, we must always bear in mind that 
a case of typhoid fever means that the victim has received 
into his digestive tract the bowel discharges of some other 
person. The only exceptions to this are those few who are 
infected by sputum spray of patients who happen to have 
the bacteria in their throats. If this general principle 
is kept constantly im the foreground, investigation and 
control of the sources of outbreaks will be much simplified. 
Yet it is surprising that many who should know better will 
ascribe the trouble vaguely to ‘ ‘ water ” or “ milk,” apparently 
not realizing that these things are mere vectors in which the 
disease cannot arise de novo. As was said at the outset, 
search for PERSONS, NOT THINGS. In our search for 
the person, however, we are compelled to follow an induc- 
tive process, so to speak, investigating in turn the various 
possible modes of transmission. 
In the earlier days of sanitary science, water~held first 
place as the vehicle by which typhoid fever was conveyed 
from man to man. Our cities and towns drank the raw 
water into which their neighbors poured their sewage, or 
they even drank their own sewage at times. That their 
typhoid fever rate could be anything else than high was not 
to be expected, for a short circuit was established between 
patient and non-immune through sewer and water pipes. 
As knowledge of the natural history of typhoid fever became 
more general and complete, this mode of transmission 
was successfully attacked and controlled. It is always to 
be considered, however, if a water supply is not properly 
safeguarded. 324 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Milk is frequently contaminated by those who have to 
do with its production or distribution. From the hand of 
the milker to that of the delivery boy, it is always subject 
to possible pollution in its passage through the dairy to the 
consumer. Many outbreaks have been traced to a case or 
carrier on a dairy. One of the authors investigated a small 
epidemic in a western town where it was found that a 
bottler in a dairy had been at work while developing typhoid 
fever. Thirty-four cases arose from this source. 
Food is occasionally contaminated in the course of 
preparation by the hands of the cook who is a carrier. 
An outbreak of this type was traced to a dish of macaroni 
served at a large picnic. The dish had been prepared by a 
typhoid carrier and it was found, by duplicating the process, 
with a culture of bacteria added purposely, that baking 
did not destroy those organisms in the center of the mixture. 
Evidently heat was not applied for a sufficient length of 
time to penetrate thoroughly. 
It has been definitely proved that flies can carry typhoid 
bacilli on their feet and in their digestive tracts. That they 
deposit bacteria wherever they alight is demonstrated by the 
growth secured on sterile dishes of culture medium when 
thus contaminated. Typhoid bacilli have repeatedly been 
recovered from the feet and excreta of flies. Wherever 
human excrement is deposited, there will be found the fly. 
If no barrier is erected against him, he will promptly carry 
his burden of disease-laden filth to the kitchen and the 
table. 
A considerable number of cases of typhoid fever arise 
from direct contact with the patient, or with things he has 
recently soiled. Since the bacteria are found in all parts 
of the body during disease, all secretions and excretions 
can be considered as infective, at one time or another. This 
is constantly true of the urine and feces. It is dangerous, TYPHOID AND PARATYPHOID FEVER 
325 
therefore, to tell the family of a patient that typhoid fever is 
not contagious. If discharging abscesses or sinuses develop 
in the course of an attack, they should receive particular 
attention, for typhoid bacilli abound in their exudates. 
We have already spoken of contamination by the hand 
of milker or cook. It is by this means that the typhoid 
carrier most frequently spreads his infective excreta 
broadcast. The carrier condition is the most prolific 
source of endemic typhoid fever in any community, while 
it may also give rise to extensive epidemics at times. 
All active cases are carriers for a period of two to eight 
weeks after fever has subsided. Some few become chronic, 
discharging typhoid bacilli constantly or intermittently for 
years, or even a lifetime. Their proportion in the total 
population of any city has been estimated from laboratory 
investigations to be 0.3 per cent, to 0.4 per cent, of the whole. 
That they are of extreme importance is illustrated by the 
famous case of “ Typhoid Mary.” Because some have 
regarded this history with skepticism, we give it at length 
in the words of the bacteriologist who traced her wanderings 
and had her case in charge. The following is quoted from 
Park and Williams, “ Pathogenic Microorganisms.” 
“A remarkable case of a cook (“Typhoid Mary”), dis- 
covered by Soper, was under our care for three years. A 
visitor of the family in which this woman was cook developed 
typhoid fever some ten days after entering the household. 
This was in 1901. The cook had been with the family 
three years and it is difficult to judge which infected the 
other. The cook went to another family. One month 
later the laundress in this family was taken ill. 
“In 1902 the cook obtained a new place. Two weeks 
after arrival the laundress was taken ill with typhoid fever; 
in a week a second case developed and soon seven members 
of the household were sick. 326 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
“ In 1904 the cook went to a home in Long Island. There 
were 4 in the family as well as 7 servants. Within three 
weeks after arrival 4 servants were attacked. 
“In 1906 the cook went to another family. Between 
August 27 and September 3, 6 out of its 11 inmates were 
attacked with typhoid. At this time the cook was first 
suspected. She entered another family on September 21. 
On October 5 the laundress developed typhoid fever. 
“In 1907 she entered a family in New York City, and 
two months after her arrival 2 cases developed, 1 of which 
proved fatal. 
“The cook was removed to the hospital March 19, 1907. 
Cultures taken every few days showed bacilli off and on for 
three years. Sometimes the stools contained enormous 
numbers of typhoid bacilli and again for days none would be 
found. She was released on parole in 1910, promising to 
report to the Health Department and not to engage in 
cooking. She broke her parole and disappeared. In 1915 
in an epidemic of typhoid at a maternity hospital, a total 
of 25 cases developed. Investigation showed that food 
infection was the cause and the cook was identified as 
“Typhoid Mary.” During the disappearance she infected 
a friend and was the cause of several cases in a small private 
sanatorium. She is known to have been the cause of at 
least 50 cases of typhoid fever. We recently traced some 
hundreds of cases of typhoid fever to a milk supply produced 
at a farm, looked after by a typhoid carrier who had typhoid 
fever forty-seven years ago.” 
Simon gives an equally striking example of long con- 
tinued carrier infection, while the literature is full of many 
other instances. 
In closing our discussion of the transmission of typhoid 
fever we can do no better than to quote the words of Dr. 
William Budd, an English physician writing upon the 327 
TYPHOID AND PARATYPHOID FEVER 
subject in 1873; “The members of the great human family- 
are bound together by a thousand secret ties of whose 
existence the world in general little dreams. And he that 
was never yet connected with his poorer neighbor by deeds 
of charity or love, may one day find, when it is too late, 
that he is connected with him by a bond which may bring 
them both to a common grave.” 
Diagnosis.—In the absence of an outbreak, typhoid fever 
is often confused with such diseases as malaria, influenza, 
pneumonia, tuberculosis, paratyphoid fever, and, in some 
localities occasionally, with Malta fever. Aside from the 
clinical evidence, reliance should be placed upon the 
laboratory for differentiation. 
* In the first week of infection, the blood carries its highest 
percentage of bacteria. At that time a blood culture will 
demonstrate the presence of infection in the majority of 
cases. As the disease progresses the bacteremia diminishes, 
but a new feature of importance presents itself, viz., the 
agglutinating property of the blood serum which gives us 
the Widal reaction. This test is practically specific for the 
infecting organism, whether typhoid or paratyphoid. In 
the latter disease, however, the reaction appears earlier than 
in the former. 
Some care must be exercised in interpreting the Widal 
test, as it will persist for years in a person who has had 
typhoid fever and is present for at least two years in those 
who have had prophylactic vaccination. Another point of 
interest is that in a person vaccinated against typhoid 
fever only, and suffering from paratyphoid fever, his blood 
serum may agglutinate typhoid bacilli more strongly than 
it will the paratyphoid organism causing his infection. 
Thus a case of the latter disease may occasionally be 
incorrectly diagnosed as typhoid fever. However, from 
the standpoint of sanitary control this is unimportant. 328 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
A carrier will usually give a more strongly positive Widal 
than a non-carrier who has recovered from typhoid fever. 
This is important in a search for possible carriers during an 
outbreak of the disease. Final determination of the carrier 
state, however, should depend upon repeated bacteri- 
ological examinations of both stools and urine. 
Methods of Control.—The individual cannot protect 
himself against typhoid fever unaided, save by the regular 
use of vaccine. The problem involves individual, household 
and community cooperation. 
A person suffering with the disease may be dangerous 
to his immediate entourage and also to the community; 
in the first case by contact, and in the second by dissemina- 
tion of his excrement. To protect others who are in imme* 
diate contact, prophylactic vaccination should be done 
promptly and concurrent disinfection of all discharges and 
of articles soiled with them should be established at the 
first suspicion that typhoid is present. The stools and urine 
are particularly dangerous and must be thoroughly mixed 
with a strong disinfectant, allowing them to stand in this 
solution for two hours, before being disposed of. Their 
final disposition is also important, as a few bacteria may 
occasionally escape destruction. Where water carriage sew- 
age disposal is not available, the stools and urine should be 
buried in the ground at a distance from any well or garden. 
The depth at which they are buried must not be over 
one foot, as we rely upon the soil bacteria for further 
purification. 
As added protection to the community, flies must be 
rigorously excluded from the sick room and from contact 
with the patient’s discharges. If any member of the family 
is engaged in milk or food handling, he should never be 
permitted to have access to the sickroom or to touch any- 
thing that the patient has handled. TYPHOID AND PARATYPHOID FEVER 
329 
As was stated earlier, the convalescent patient is a carrier 
for a greater or less period of time. Many health depart- 
ments require that his stool and urine be submitted to an 
approved laboratory for examination as to the presence or 
absence of typhoid bacilli. If present, the patient is 
released only under especially prescribed conditions, and 
these conditions should remain in effect until at least 
three successive negative specimens, taken fifteen days 
apart, have been secured. Until such conditions have 
been met, the carrier must be considered dangerous and 
under no circumstances should he be permitted to engage 
in the production or handling of milk or other food for 
public consumption. 
Control of the chronic carrier is a vexing public health 
problem. Some gradually eliminate their infection by 
natural processes, but others may continue to discharge 
organisms for a lifetime. No medical treatment so far 
devised has cured all cases. Better results have been 
secured by removal of the gall bladder, for it has been 
demonstrated that it is this organ which harbors the organ- 
isms and permits their multiplication. Experimental evi- 
dence indicates that only an inflamed gall bladder will 
retain the bacteria and it has been further shown that the 
condition is quite frequently associated with gall stone 
formation. This latter fact can be used in making a 
search for carriers, as a history of disturbance in the gall 
bladder wmuld indicate thorough examination of stools in a 
person already under suspicion. 
While chronic carriers usually discharge bacilli con- 
stantly, a single negative test should never be accepted as 
final, especially in the face of a positive Widal, or of indi- 
cations of gall bladder inflammation. We occasionally 
find an “intermittent” carrier who may give one or two 
negative specimens before the bacteria are found. 330 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
The investigation of an outbreak of typhoid fever 
affords the health officer a most interesting opportunity to 
apply his knowledge of epidemiology. While he is certain 
that a person is ultimately responsible for the infection, 
he may be compelled to follow many clues before definite 
solution of his problem is reached. 
Water borne outbreaks may be explosive in character, 
or may develop gradually and continue over a long period 
of time, dependent upon whether they are caused by a 
single large pollution, or by a constant and smaller one. 
Often it is necessary to make a survey of the entire water 
shed in order to discover the source of contamination. 
Closely allied to the question of water purity is that of 
sewage disposal above the source of supply and the method 
of sewage treatment. This entire subject is considered 
elsewhere. 
If a water supply is proved to be above reproach, we 
still have to deal with those other factors that are respon- 
sible for what is termed “residual” typhoid. Of these 
milk is the most common medium for typhoid dissemination, 
for it is handled by many persons and is an excellent 
culture medium for bacteria. The characteristic of most 
milk borne outbreaks is their explosiveness, all cases 
developing together within a week or two. A carrier is 
usually responsible for such contaminations. Constant 
and thorough inspection of dairies is the remedy, together 
with pasteurization. The latter should always be insti- 
tuted as an emergency measure, if the milk supply is 
suspected. 
Food is occasionally a factor in spreading typhoid fever, 
due to contamination directly by a carrier or by typhoid 
bearing sewage. 
In small towns and rural districts the fly probably plays a 
leading role in disseminating typhoid because of the TYPHOID AND PARATYPHOID FEVER 
331 
universal prevalence of insanitary privies or the disposal 
on the open ground of human wastes from typhoid cases or 
carriers. Rural sanitation is doing much to eradicate 
this evil, but must wait upon full-time health organizations, 
before rural typhoid can be reduced in proportion to the 
reduction accomplished in cities. At present, the amount 
of typhoid fever in any state is directly proportional to the 
percentage that the rural population bears to the whole. 
The one method of typhoid fever control that would give 
the largest reduction in the shortest time is universal 
vaccination. While its complete application can never be 
expected, much can be done to educate the public to its 
acceptance, by offering the excellent evidence which we 
have of its efficacy. 
Education in hygiene and sanitation will be a potent 
factor in the eradication of typhoid in proportion to the 
energy exerted by the health authorities in its dissemination. 
The public is genuinely interested in health protection, but 
it does not want a mass of vague theories, such as have 
been served up in the past, only to be repudiated. The 
health officer should take the public into partnership 
in his program of sanitation, for the public is, after all, 
the most interested party in the matter. 
To sum up, then, typhoid fever control can be expressed 
in one word, CLEANLINESS in its sanitary significance; 
clean water, clean milk, clean food, clean excreta disposal, 
clean patients, and, always, clean hands. Lacking these 
essentials, we shall continue to have typhoid and to demon- 
strate thereby that it really “is a disease of defective 
civilization.” 
Mortality.—In 1918 there were 10,167 deaths from 
typhoid fever in the Registration Area of the United States. 
Of these deaths 6,405 were in the rural sections of the regis- 
tration states. On an average there are ten times as many 332 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
cases of typhoid as there are deaths, which would give 
over 100,000 cases for 1918 in the Registration Area alone. 
Taking the figure 0.3 as the percentage of chronic carriers 
arising in the population generally, we find that over 
300 such persons were turned loose upon their communities 
in this area alone, each one becoming a potential source 
of disease and death, for many years or for life. Until 
public intelligence is aroused to the point of demanding 
a thoroughly scientific attack upon the disease, typhoid 
fever will continue to reap its annual harvest of death. 
38. TYPHUS FEVER 
Typhus fever, formerly known as “ship” or “jail” 
fever, was confused with typhoid and relapsing fevers for 
many years. It is the rise of bacteriology that made exact 
differentiation among these diseases possible. Typhus, 
once a major disease, declined rapidly in frequency and 
virulence in the civilized world during the nineteenth 
century, but subsequent to the World War it spread in 
epidemic form through the Near East, and has invaded 
portions of Central Europe. The fact that typhus is 
endemic in Mexico, and that cases occasionally present 
themselves at the International Boundary, brings the 
menace to our own doors and demands our especial interest 
in the disease. It has gained entrance through eastern 
ports, on several recent occasions, and an outbreak also 
occurred among thej Navajo Indians in the spring of 1921. 
We should note that the so-called “Brill’s Disease” 
seems to be a modified form. In this attenuated form 
typhus is to some extent endemic in several of our larger 
cities. 
Infective Agent.—The specific organism of typhus has 
not been finally identified. A minute body designated 
as Rickettsia prowazeki appears to be the infective agent, TYPHUS FEVER 
333 
but the evidence is not all in, as yet. Cultivation in the 
laboratory has been beset with difficulties. 
Incubation Period.—Experimental typhus in the guinea 
pig has an incubation period of from 7 to 10 days. 
Immunity.—There is only a slight degree of natural 
immunity to typhus in the general population. Immunity 
to the more severe form of infection may be acquired by 
an attack of the disease or of the mild type described 
by Brill. The work done by Plotz, by which it was 
originally hoped to demonstrate the causative organism 
and make possible a prophylactic vaccine, has not been 
confirmed. 
Modes of Transmission.—So far, the only known natural 
method of transmitting typhus is by the bite of the body 
louse that has previously fed on an infected person. This 
fact has been well established by experimentation. Infec- 
tion may be experimentally transferred through injection of 
the blood of a typhus victim into a healthy individual. 
All the elements of the blood seem to carry the infective 
agent. No other methods of infection have been demon- 
strated. Lice that have bitten typhus patients are said to 
retain their infectivity from 2 to 10 days. It has not been 
fully demonstrated whether the virus is injected with the 
bite or is discharged upon the skin with the dejecta of 
the louse, to be rubbed into the minute wound by the 
victim himself. 
Diagnosis.—Typhus is to be distinguished from typhoid 
and the relapsing fevers. This is easily done in the case 
of typhoid by the presence of a positive Widal reaction. 
Relapsing fever shows the spirillum of that disease in the 
blood. Another affection which might possibly be confused 
with typhus is Rocky Mountain spotted or “tick” fever. 
The onset in the latter, however, is usually much more 
gradual, occupying a period of five days or more before 334 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
fever reaches the fastigium. The outstanding features of 
typhus are the sudden onset, headache, prostration, and 
an eruption which gives a dusky red color to the skin, inter- 
spersed with rose spots and petechiae described as resemb- 
ling a mulberry. The eruption choses the trunk and 
extremities rather than the face. 
Guinea pig inoculations with the patient’s blood serve 
to distinguish typhus from Rocky Mountain spotted fever. 
The latter disease produces gangrenous areas in the skin 
of the animal, which is not the case in typhus. 
An agglutination test, known as the Weil-Felix reaction, 
is considered as specific in typhus. The patient’s blood has 
the power of clumping a proteus-like bacillus, through the 
formation of a non-specific agglutinin. This is a quite 
unusual phenomenon among such reactions. 
Methods of Control,—Control of typhus depends 
upon eradication of the louse. This subject was discussed 
in the chapter on pediculosis, and will not be repeated here. 
No other precautions are necessary, in the presence of 
typhus, than to prevent infestation with lice. Closely 
fitting garments, closed at the openings with adhesive 
plaster, should be worn by all attendants. When these 
garments are removed, they should be wrapped in a 
sheet and steamed or boiled, or soaked in gasoline, before 
being handled again. Delousing measures should be ap- 
plied to the affected population groups at once, when- 
ever typhus is diagnosed. See the appendix for delousing 
methods. 
Contacts should be held in quarantine at least 14 days, 
and better for 21 days. 
Mortality.—Typhus has a case fatality rate of about 
20 per cent, in the severe type. Mortality rises rapidly 
after 30 years of age and nearly all persons beyond 50 succumb 
to typhus. Brill’s Disease is not fatal in more than one per THE VENEREAL DISEASES 
335 
cent. For this reason, infection with the latter disease 
has been recommended as a prophylactic for those who must 
work in typhus districts. 
39. THE VENEREAL DISEASES 
The four diseases which form the subject of this and the 
following section constitute the most serious problem, by 
far, that confronts the sanitarian. Destructive though 
tuberculosis and cancer may be, they are far outdistanced 
by syphilis alone, which lays its blighting hand upon one 
tenth of our people and claims for its own even the second 
and third generations of those who fall its victims. 
Yet, six years ago, scarcely a state required that these 
diseases be reported. They were rarely mentioned in the 
public press. To speak of them outside of professional 
circles was to brand oneself as vulgar. In so short a space 
of time has public sentiment been reversed that practically 
every state requires that they be reported and controlled. 
The daily papers carry many columns of news matter regard- 
ing them. Their nature and prevention are being taught 
in our elementary schools and higher institutions of learn- 
ing. A great army of men and women is engaged in many 
lines of activity directed toward their eradication. This 
movement denotes a healthy tendency in that such diseases 
are being lifted from the realm of the quack, the dive keeper, 
the grafting politician, the limbo of things taboo, and 
placed where they rightfully belong among those problems 
of medicine, hygiene and sociology that are receiving the 
earnest attention of the most able minds. 
A realization of the extent to which syphilis and gonor- 
rhea were sapping the vitality of our race had been growing 
among those who had made a systematic study of the 
problem, for several years prior to the war. It was the 
gathering of our young manhood in the camps, however, 336 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
which crystalized this sentiment into the most compre- 
hensive program of health education ever conceived, 
education which is today finding its way into the remotest 
hamlets of our land. To this problem, developed by our 
government and adopted by every state of the Union, wTe owe 
that enlightened public opinion which demands that these 
diseases be dragged into the open and destroyed. 
For many generations, profession and laity alike have 
grouped the four diseases which we are discussing under 
the heading “venereal” or “social diseases,” or “bad 
diseases,” thereby stamping them as vulgar, or worse, 
and placing their victims without the social pale. We know 
now that no more unscientific and disastrous policy could 
have been adopted. The newborn infant, blind because 
of a gonorrhea in its mother, is surely no hardened sinner. 
The innocent wife made childless and a life-long invalid, 
because of an infection from her husband, is no evil doer. 
The trusting young girl who acquires a chancre of the lip 
from the kiss of her lover is no moral outcast. Yet these 
innocent infections constitute a high percentage of the 
so-called “venereal” diseases and those who suffer their 
effects have been classed with the prostitute, the pimp and 
the criminal. But a better day is upon us and we are 
learning to recognize these diseases as exactly on a par with 
all others that are infectious and, therefore, within the 
purview of the health authorities. 
Not until the war called together our young men from 
every state did we realize the full extent to which such 
infections had taken root among us. Of the second million 
who came to the army camps, an average of over five in 
every hundred were suffering from one or more of these con- 
ditions. For various states these figures differed through 
a wide range. What the figures would be if we could count 
every woman infected, every child with gonorrheal oph- THE VENEREAL DISEASES 
337 
thalmia or hereditary syphilis, every older man with latent 
disease in his body, no one can say. 
However, it is not in numbers alone that these diseases 
hold interest for the health officer, but in their profound and 
far-reaching effects. As has been suggested, gonorrhea 
is an important cause of infant blindness. Moreover, 
about 75 per cent, of women who come to the operating table 
for pelvic conditions are brought to their pitiable condi- 
tion by the affection. One writer has said that, were it 
not for gonorrhea, the specialty of gynecology would be 
merely an insignificant branch of abdominal surgery. 
But gonorrhea, with all its train of ills, is as nothing when 
compared with syphilis. Osier said that to know syphilis 
in all of its manifestations vras to know the practice of 
medicine, for there is scarcely an ailment known to the physi- 
cian which syphilis may not simulate at some stage of its 
development in various patients. No tissue or structure of 
the body escapes its inroads. Even the foundations of reason 
may fall before its attack, while the unborn babe, and the gen- 
eration to follow it, are not spared. Is not such an adversary 
worthy of the best efforts of the world to conquer it? 
Space will not permit of more than an outline of the 
subject. However, because of its supreme importance, a 
separate section will be devoted to the question of control, 
which is much the same for the entire group. 
BALANITIS GANGRENOSA 
Because it is a genital infection, balanitis gangrenosa is 
included in the group of “ venereal” diseases. It is rather 
rare and has no great importance, except to the unfortunate 
victim, in whom it often produces a complete destruction of 
the external genitals. A condition known as erosive vulvi- 
tis, in females, has recently been rather conclusively shown 
to be identical with balanitis of the male. 338 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Infective Agent.—The infective agents are a spirochaete 
and a fusiform bacillus, which are always associated in the 
lesions. 
Incubation Period.—The incubation period is not defi- 
nitely known. 
Immunity.—Although we do not known positively, it is 
probable that there is a rather high immunity to this infec- 
tion, for it is comparatively rare. 
Modes of Transmission.—There is but one mode of 
transmission, through sexual intercourse with an infected 
person. It is usually found in those who are extremely 
unclean in their personal habits. 
Diagnosis.—In the male, diagnosis is easy by reason of 
the destructive gangrene that attacks the genitals, destroy- 
ing the whole external apparatus in a few hours, at times. 
In the female, as well as in the doubtful male case, recogni- 
tion of the spirochaete and its associated bacillus in smears 
of exudate from the deeper parts of the lesion will reveal 
the nature of the disease. 
Mortality.—A man occasionally dies from a rapidly 
spreading gangrene, which sweeps up over the abdomen, 
melting all structures before it. 
CHANCROID 
Chancroid is of interest principally to be differentiated 
from the initial sore of syphilis. It is painful and disabling, 
particularly when it invades the inguinal glands, but is not 
serious nor fatal. 
Infective Agent.—The streptobacillus of Ducrey is the 
causative agent. 
Incubation Period.—The lesion appears within a week 
after infection, usually in from two to four days. 
Immunity.—Probably all persons are more or less suscep- 
tible, but the organism is frail and easily killed, so that the 
incidence of infection is low. THE VENEREAL DISEASES 
339 
Modes of Transmission.—Chancroid is practically always 
acquired through sexual intercourse. From the initial 
sore the patient may infect other parts of his body, since 
the exudate is highly infectious, when fresh. Very rarely, 
intimate contact may produce an extragenital lesion in 
another person. 
Diagnosis.—The question of diagnosis of chancroid is 
closely wrapped up in the larger one of syphilis. The whole 
problem is the positive elimination of the latter infection, 
and what is said as to diagnosis of the initial lesion of 
syphilis applies as well to chancroid. No person who is 
familiar with the two diseases will attempt, today, to make a 
diagnosis upon the appearance of the sore alone. To do so 
is to be guilty of malpractice and to endanger the future 
happiness and the very life of a patient. REPEATED 
DARK FIELD EXAMINATIONS OF EXUDATE 
FROM THE UNTREATED LESION IS THE ONLY 
SAFE PROCEDURE. Even then, the patient should be 
carefully watched for constitutional symptoms suggesting 
syphilis and many Wasserman tests made upon the slightest 
suspicion of the latter disease. 
Mortality.—The disease per se never kills, but a complicat- 
ing septicemia may occasionally result fatally. 
GONORRHEA 
In times which are happily past for the most part, the 
medical profession maintained an indifferent or hostile 
attitude toward the patient with gonorrhea. The public 
acquired the notion that the disease was “no worse than a 
bad cold.” This combination of ignorance and indifference 
bred suffering for the patient, with frequent disaster or 
death to the members of his family. We know now that 
gonorrhea is a formidable disease, particularly when it 
affects women and when it is implanted in the eyes of 340 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
infants or adults. Of the latter affection we have already 
spoken in a former section, while the seriousness of the 
female genital infection was mentioned in the introduction 
to this discussion. 
The chief difficulties which the disease in both sexes 
presents are its resistance to our usual methods of treatment 
and its tendency to chronicity, with of ten little manifestation, 
until aroused by some extraordinary condition. Until the 
medical profession takes the trouble to become proficient in 
methods of diagnosis and treatment, and learns to treat the 
patient until he is really well, gonorrhea will continue to 
reap its pitiful harvest of wrecked homes and blinded 
children. 
Infective Agent.—The diplococcus of Neisser, or the 
gonococcus, is the infective agent. It is a small diplococcus 
that is found within the bodies of the pus cells and is nega- 
tive to Gram’s stain. It is of the same class as the pyogenic 
organisms. 
Incubation Period.—One to three days is the usual period 
of incubation. 
Immunity.—Natural immunity appears to exist in an 
occasional person, but the great majority of humanity is 
quite susceptible. One attack does not confer immunity. 
Modes of Transmission.—Practically all adult genital 
infection is acquired through sexual intercourse. This 
should by no means convey the impression that it is 
associated with illicit relations in all cases, for a large part 
of female infection is innocently acquired from an infected 
husband and the husband may so receive it from his wife. 
Genital infection acquired by other means than that men- 
tioned is so rare as to be a curiosity, when occurring in an 
adult. Eye infections of the newborn are received from the 
mother, at the time of birth, or from the contaminated 
fingers of mother or nurse, during the early days of life. THE VENEREAL DISEASES 
341 
An important phase of the disease is the vaginal infection 
of little girls, usually transmitted by the hands of the 
mother or nurse. This is a particularly distressing con- 
dition, for it is difficult to cure and may leave a girl sterile, 
or with pelvic disease, for life. Hospitals for children 
must be constantly on the alert for this affection, for it is 
easily carried on the hands of a nurse and has been known 
to spread rapidly through an institution by this means.1 
Diagnosis.—There is but one definite method of making a 
final diagnosis—the microscopic examination of a stained 
smear of pus. With a history of exposure and a purulent 
discharge from the male urethra, developing within two 
or three days, a physician should always make a tentative 
diagnosis of gonorrhea, in the absence of a microscope. 
Without the latter, it would be extremely difficult to make a 
positive diagnosis in a woman. If confirmation of a diag- 
nosis is desired, culture of the organism and a complement 
fixation test of the patient’s blood serum should be the 
final resort. 
Mortality.—Gonorrhea sometimes kills by a septicemia 
or meningitis. Its greatest mortality, however, is from 
complications, such as a heart disease or a female pelvic 
invasion necessitating operation. But we have seen many 
a woman who lived and begged for death as a welcome relief 
from suffering of mind and body. And many a man has 
endured a living death by reason of the realization that his 
home was childless, and his wife a pain-wracked invalid, 
through his own folly. 
SYPHILIS 
In his introduction to the discussion of syphilis in 
“Today’s World Problem in Disease Prevention,” Dr. 
John H. Stokes, of the Mayo Clinic, has the following to say: 
1 See Chapin, Sources and Modes of Infection, p. 165. 342 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
“ Syphilis, like gonorrhea, is an infection caused by a 
specific and definite germ. It is a master disease, the peer, 
and indeed the superior of tuberculosis, the great ‘white 
plague/ in the wide range of its influence over the fate of 
mankind, present and future. There is not a tissue or a 
structure of the body which syphilis cannot affect, nor is 
there an aspect of the entire science of medicine in which it 
will not be encountered. ... No lane is so long that one 
may not find syphilis at its turning. The disease has changed 
the destiny of mankind upon the earth. If it should cease 
at this moment to be transmitted, its effects would not 
disappear from the world within two and perhaps three 
generations. Few indeed of living human beings can boast 
an ancestry free from its remote effects. 
“ . . . Infinitely clever, infinitely versatile, even a 
little inclined to chivalry in that the disease is in general less 
severe in women than in men, syphilis is an opponent 
worthy of the subtlest resource, the most indomitable 
determination. The seeming triviality of its onset, its 
extraordinary skill as a dissembler, the silent but none the 
less terrible march of the invading host of spiral germs from 
their point of invasion through the blood to every structure 
of the body, the long years of silent, evil and yet wonder- 
fully skillful work they do under an outward aspect of 
good health, the variety of ailments to which syphilis can 
give rise, and yet the dramatic, the almost astounding 
effectiveness of proper treatment, make it decidedly unique. 
... To the appreciation of its course and its history it is 
not amiss to bring a little of the spirit of the artist, in order 
to understand the workings of this masterpiece of evil, this 
most gifted of all the unholy fellowship of devil’s aides. ” 
Thus is expressed the sentiment of one who has had an 
unusually wide and varied experience with the disease. To 
give the subject anything like an adequate presentation THE VENEREAL DISEASES 
343 
would be beyond the scope of this book. Suffice it to say 
that the above characterization is well within the limits of 
verity, when we consider the host about us of tabetics, 
insane, imbecilic, crippled, deformed, invalided women and 
horribly disfigured men, who have been brought to their 
pitiful condition by syphilis. And there must be added to 
their number that unseen host of children stillborn, or dead 
from premature birth or from the early ravages of heredi- 
tary infection. 
Infective Agent.—Spironema pallidum is the infective 
agent. Formerly it was designated spirochaeta pallida, 
then by later investigators the term treponema pallidum 
was preferred. It is a long, corkscrew-shaped, actively 
motile organism that is difficult to stain and to cultivate 
in ordinary media. Researches published in 1920, under 
the auspices of the Interdepartmental Social Hygiene 
Board, have given us a method of staining1 and one of 
anaerobic cultivation that appear to be quite promising 
and more easily applied than the older procedures. 
Incubation Period.—From one week to one month may 
be required for the initial sore to develop from an infection. 
Immunity.—There is practically no natural immunity 
to the disease. All ages are susceptible, from the unborn 
infant to the senile. A second fresh infection is not usually 
acquired while the disease is present, but recently, reports 
have been made of cases in which a second infection had 
followed a cure with the newer remedies. 
Modes of Transmission.—Perhaps the greatest number 
of cases arise through sexual intercourse. Again it should 
be emphasized that women are often innocently infected 
1 Rosenberger and Franz developed methods for staining the organism, 
while still moist on the slide. One process employs aniline black and the 
other dahlia. The latter is a so-called “vital” Stain, combining with the 
living cell and killing it as an increasing amount of the dye is absorbed. 344 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
by their husbands. Dr. Stokes, who was quoted above, 
estimates that 50 per cent, of female patients are so infected. 
Men sometimes receive it from their wives. 
Extra-genital infections may occur on any part of the 
body. The lips and mouth are common sites and usually 
receive the germs from a person having ulcers in the mouth, 
or from some article which such a person has recently had 
in his mouth. Clothing freshly soiled with exudate from a 
lesion that bears the spirochaete may transmit infection. 
Considering the great frailty of the organism outside the 
body, and its lack of resistance to drying and to soap suds, 
there is little likelihood of infection from doorknobs, toilet 
seats and such articles. Only in the case of very fresh 
contamination would it be remotely possible to acquire the 
disease from these things. 
What is perhaps its most striking characteristic is the 
hereditary transmission of syphilis. Some indeed believe 
this to be its most frequent mode of transmission. At any 
time during the intrauterine life of the child it may become 
infected from its mother. Formerly it was thought that 
the infection might be acquired directly from the father, 
without the mother partaking of the disease at all. But 
later studies have demonstrated this to be an error, due 
largely to the difficulty of recognizing an initial lesion high 
in the vagina, to the more benign course often pursued by 
the disease in the infected woman, and to lack of proper 
technic in making blood tests. Growing out of this fallacy 
was Colle’s law, which taught that a syphilitic child might 
nurse from a healthy mother without giving her the disease. 
We know that the reason the mother showed no signs of 
syphilitic chancre on the nipple was because she already had 
an infection. 
Diagnosis.—Many persons developing the late mani- 
festations of syphilis have been the victims of faulty diag- THE VENEREAL DISEASES 
345 
nosis at the time that the chancre first appeared. Let us 
repeat here what was said of chancroid, that the more 
experience a physician has with the two diseases the less 
is he willing to risk a diagnosis upon the appearance of the 
sore. With the dark field method available to anyone 
who will take the slightest trouble to procure inexpensive 
equipment, no physician does his duty by a patient if he 
does not use it. At the time of the initial sore syphilis is 
nearly always LOCAL. When the secondary symptoms 
have appeared it is SYSTEMIC. While local, it is 
amenable to abortive treatment. A few days later it is 
not. The difference between the twro means years of 
treatment and may make the difference between cure and 
arrest of the disease. Therefore, USE THE DARK FIELD 
EARLY AND OFTEN. Further, do not treat the chancre 
at all until diagnosis is made. One local application of the 
mildest sort may drive all spirochaetes deep into the tissues. 
A recently developed staining method, mentioned above, 
may also prove of value in early diagnosis. 
Once the infection has invaded the body another method 
of diagnosis becomes available, viz., the Wassermann 
test. To discuss its uses and interpretations here would 
completely fill the limits of this book. 
The physician must interpret reports upon Wassermanns 
in the light of all the data which he may have in regard to 
his patient’s history and symptoms. It is of particular 
importance to note that a SINGLE NEGATIVE 
WASSERMANN GENERALLY MEANS NOTHING. 
Repeat again and again, if negative, and if the history 
or clinical symptoms warrant a suspicion of such infection. 
On the other hand, a doubtful or one-plus Wassermann 
may not mean syphilis. 
A refinement of the Wassermann test is that done upon 
the spinal fluid. This may frequently show disease of the 346 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
central nervous system when the blood is persistently 
negative. 
A further test which reveals the beginnings of those most 
terrible of all the late syphilitic manifestations, paralysis 
of the insane and locomotor ataxia, is the colloidal gold 
test done on the spinal fluid. In the hands of an expert 
it gives quite uniform results and is invaluable to the patient, 
as it may mean the one chance of rescue from insanity and 
paralysis. 
Since syphilis is so protean in its manifestations, it may be 
necessary to differentiate it from almost any other disease 
to which flesh is heir. And by reason of this fact, an 
underlying syphilis may be suspected in any condition that 
cannot be readily explained by other causes. 
Mortality.—In ages past, syphilis was an acutely fatal 
disease, destroying its victims in a few weeks. Time has 
conferred some degree of resistance upon the race, so that 
we rarely see such cases today. But the rapidly fatal 
termination would often be a boon to those who must die 
by inches from paresis, from tabes, from organic involve- 
ment, or from congenital debility. Taking these late 
developments of the disease into consideration, we may say 
that the mortality of untreated syphilis is high. 
Early diagnosis and thorough treatment mark the way of 
salvation for the syphilitic. 
40. THE CONTROL OF VENEREAL DISEASES 
“Venereal diseases have at last been recognized as 
prevalent, destructive and preventable. They have been 
brought into the open and they cannot stand the light.” 
Thus Wilbur A. Sawyer, M.D., formerly Major, M.C., 
U.S.A., sums up the present attitude toward what was 
but recently regardedAas impossible. We have already 
seen that these diseases are more widely prevalent than THE VENEREAL DISEASES 
347 
any of the communicable diseases. That they are terrible in 
their destructiveness has been demonstrated. It remains 
for us to study the methods by which they may be controlled. 
At the outset it would be well to recall that these infec- 
tions are similar in all respects to other communicable 
conditions. We know their sources, and the causative 
organisms. We know that they are transmitted by contact 
direct or indirect. Indeed we are in a better position in 
respect of these affections than with many others that have 
been controlled effectively. But long accepted convention 
had set up a barrier of silence about them, and had created 
public conviction to the effect that nothing could be done 
to control them. As a convincing refutation of this opinion, 
the plans outlined in this chapter are presented, not as 
theories, but as things that have actually been put into suc- 
cessful practice in this country during the last five years. 
Every study of the source of venereal infection leads 
ultimately to the prostitute, whether commercial or 
amateur. The hereditary syphilis of the babe traces its 
origin directly through innocent mother, through father 
to prostitute. Gonorrheal ophthalmia in the new born 
follows the same route. On the face of it, then, the 
solution looks simple— no more prostitutes, no more venereal 
infection. But a little study of the business of prostitution 
will show that such is not the case. 
To the average person it comes as a startling revelation 
that prostitution is a well organized and widespread 
business. An examination of the voluminous report of 
the Bureau of Social Hygiene of New York, published under 
the title “Commercialized Prostitution in New York,” is 
enlightening on this point. The Bureau employed trained 
investigators who spent a year working on the subject, 
in intimate, daily contact with those whom they were study- 
ing. They passed themselves off as persons who were in the 348 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
business and thereby learned the most minute details. As 
a result they secured a mass of reliable information. 
For a period of months these investigators counted every 
woman whom they found in a house of prostitution and 
arrived at the total of 14,926. These figures were for the 
regular houses alone and did not include those who fre- 
quented hotels, lodging houses and all the others of the 
group commonly designated “clandestine.” The investi- 
gators found 15 to 25 women to each house. Moreover, 
they estimated that at least $2,000,000 had been paid to 
women in these houses in one year. 
But such a tremendous business as this does not “just 
grow.” The women engaged in it are the employees of 
men and women higher up, for the most part. As any 
other business man would do, this group of vultures 
deliberately fosters “trade” by the use of every artifice that 
would tend to incite susceptible men. Furthermore, 
they are constantly on the lookout for new recruits in 
their houses, and this is one of the blackest pages of their 
history. For only in the rare instance does a woman 
deliberately choose the life. She is usually the victim of 
our vicious “conspiracy of silence” which denies the inno- 
cent girl any wholesome instruction on the subject of sex, 
and then casts her out as a moral leper when she has fallen 
a victim to those things that she knew nothing of. Many 
of these girls are below par mentally, some of them actually 
feeble minded, incapable of making wise moral decisions 
and fit only for institutional care. In California 30 per cent, 
were found to be such by careful psychological analyses. 
That a business of this magnitude will not die easily is 
self-evident. Those who derive the larger incomes from 
it are well organized and have entrenched themselves in 
some governing bodies. It is from them and their political 
henchmen that we hear reiterated the old platitudes that THE VENEREAL DISEASES 
349 
men always have and always will demand prostitutes. 
And it is through their subtle machinations that many an 
effort to curb the evil has come to naught. 
Every woman who gives herself to promiscuous relations 
is a potential source of infection. What then, are the 
figures as to disease among such? The New York report, 
above referred to, throws interesting light upon this 
question. Of 466 women examined at the Bedford Refor- 
matory, only 50, or 10.7 per cent, were entirely free of infec- 
tion as shown by complement fixation tests. Not all of these 
women were from houses of prostitution, but all were of 
the sort who would consent frequently to illicit relations. 
Among other things the figures illustrate the fallacy of 
many a young man’s argument that he cannot contract 
disease because he is very careful as to whom he chooses 
as a partner, and never enters a regular house. 
Bearing these figures in mind, let us look at the number of 
possible exposures to infection. One New York investi- 
gator found a woman in one house whose card bore 30 
punch marks, indicating that she had as many visitors 
in one night. In Chicago, the Vice Commission observed 
one house for 22 months. In that time there was an 
average of 18 inmates who had 15 visits each per night. 
The New York Bureau estimated, from their figures, 150,000 
exposures per day. The wonder is that we do not see a 
greater amount of infection. 
Thus hastily have we surveyed the problem of commer- 
cial prostitution. What is to be done about it? At the 
beginning of the World War Surgeon-General Gorgas 
said that if he could choose between eliminating all battle 
wmunds and all venereal infection, he would choose the 
latter, for he realized their direful consequences to the 
nation, to the Army and to the individual. Past history 
had taught him that these diseases were far more destruc- 350 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
tive to manpower than the enemy’s fire. Out of the 
realization that our soldiers must be protected as far as 
possible from such infection grew the American plan for 
the control of venereal diseases. This plan has been 
accepted as a model for the world and has been studied 
by representatives of many foreign countries. 
The prime essential of this plan is the suppression of 
prostitution. No compromise is made, but the business 
is eliminated as completely as possible. This calls for 
complete cooperation on the part of local officials, backed 
by laws with adequate penalties and no loopholes. Such 
a policy has been adopted by many states as a whole. 
Houses are closed; personal and real property used for 
such purposes is seized; the women and their employers 
are placed in detention homes or jails; and the men who 
are found associated with them are treated upon the same 
basis as the women. This latter is an advanced step. 
To treat the male offender exactly as the female is treated 
is an innovation, but one that is in all respects just. 
In many states the procedure followed with both men 
and women, who are arrested under the laws controlling 
prostitution, is for the court to hand them over to the health 
authorities, who, while holding them under quarantine, 
examine and treat them. When they are found to be no 
longer infective, they are returned to the jurisdiction of 
the court for sentence. In other states treatment and 
sentence run concurrently. This latter method is not 
satisfactory, as the jail term does not usually allow time 
to render the prisoner non-infective. Besides, it is essen- 
tial to keep clearly differentiated in our minds the isolation 
because of infection with communicable disease, and jail 
detention as a punishment for moral turpitude. 
Another logical procedure is the attempt to rehabilitate 
the women, so far as possible, by giving them vocational THE VENEREAL DISEASES 
351 
training whereby they may support themselves decently, 
after release. Those who are not capable of acquiring 
such training are held permanently in detention homes or 
farms, where they can no longer be a menace to society. 
Obviously, to drive the prostitutes out of a town, without 
making any provision for their care, is merely to sweep 
the trash from one’s own yard into one’s neighbor’s. To be 
effective, the plan must be worked as a whole. And it is 
encouraging to note that many states are doing all of these 
things successfully. Space will not permit of more than 
this bare enumeration of activities, but details may be 
secured from the U. S. Public Health Service. 
That the plan is worth its cost can hardly be gainsaid. 
Every prostitute isolated and rendered non-infective 
reduces exposure to that extent. Infection prevented, 
especially syphilitic, will have its effect far beyond the im- 
mediate generation. Growing boys and girls will no longer 
see immorality publicly flaunted and openly connived at. 
Several objections to the plan are usually offered and 
should be answered. The first one generally heard is 
that men will seek clandestine modes of satisfaction, 
if deprived of public prostitutes. We must admit that 
an appetite equally as fundamental as that for food is not 
easily controlled. But it is the practice of the professional 
prostitute and her employers deliberately to present tempta- 
tion and to arouse dormant passion by every device known, 
in order to increase business. Artificial stimulation of this 
sort will be removed. The knowledge that satisfaction is 
not so easily had will restrain desire to a certain extent. 
A closely allied proposal is that prostitutes should be 
segregated in a designated district and periodically 
examined for the presence of infection. Many investiga- 
tions have been made of women who have been thus 
examined, and they have been repeatedly found to be 352 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
harboring infection. It could hardly be otherwise when 
we consider the immense amount of male infection and the 
number of times that a woman may be exposed in a single 
day. A report on a certain city, from federal workers, 
states that 40 certificates of freedom from infection were 
taken from women detained in a hospital because of 
venereal disease. These certificates had been issued by 
physicians, some of them in high standing. A man seeing 
such a certificate exposes himself to infection all the more 
readily. Part of the program above mentioned is to 
prohibit the issuance of certificates of this sort entirely. 
A further objection raised is that the suppression of 
professional prostitution does not reach the amateurs, 
and that these may harbor more virulent infections than 
the professionals. The amateur, if she causes infection, 
may be isolated and treated just as effectively as the pro- 
fessional. Though it may not be so easy to locate the 
former, it can be, and is being, done in some states. The 
Army, cooperating with civilian authorities, succeeded 
in isolating many infected amateurs in the vicinity of 
cantonments, and one of us has isolated infected women of 
this class in a western state. But, regardless of the viru- 
lence of infection or the difficulty of apprehension, it must 
be borne in mind that the amateur seldom exposes more than 
one or two males in a week, while the regular prostitute 
exposes many every night. The difference in number of 
exposures counts heavily in the spread of infection. 
Many other objections are made, some of them sincere, 
but more, by far, emanating from those who profit in the 
business. That none of them is sound has been demon- 
strated by the fact that the plan as outlined works. 
We must admit that fear of consequences or a cold ideal- 
ism alone will not deter many from exposing themselves to 
infection. As Dr. Stokes points out in his admirable book, THE VENEREAL DISEASES 
353 
there must be a moral bulwark built upon proper education 
of the young, coupled with active physical development 
and high ideals. 
Parents must teach their children the fundamentals of 
sex from the time the first questions are asked. In this 
enlightened day a grave responsibility rests upon those 
who allow their boys and girls to grow up without such 
instruction. The fond delusion exists that their children 
are ignorant and therefore innocent. All who have to deal 
with children in schools and elsewhere know that this is 
not true. Any adult can remember the vileness of things 
he heard in school and at play. Yet the average adult will 
blindly believe that his child is not absorbing the same 
sort of thing. Is it not better to teach the child correctly 
and fully in the beginning, than to have him secure his sex 
knowledge only from obscene associates? That he will 
get it somehow no one can be gullible enough to deny. 
For those who are in doubt as how best to present the 
subject to their children, many helpful books and pam- 
phlets have been prepared by various social agencies, 
among them the American Social Hygiene Association, 
370 7th. Ave., New York, N. Y. 
Education begun at home should be carried on in the 
schools. Courses in physiology, biology and hygiene can 
make the subject of sex clear and at the same time present 
it without arousing self-consciousness. The reproductive 
function can be shown in its true relationship as a part of 
the natural growth of the body, necessary to physical and 
mental development. Thus a sound foundation can be laid 
for a superstructure of ethical ideas. Cooperation of the 
church, of social agencies and of the state should be had in 
this educational campaign, in order that all may be reached 
and that the lesson may become indelibly impressed upon 
minds in their most receptive period. The ideals of love, 354 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
marriage, homemaking and parenthood should be held 
before older boys and girls as the highest expression of their 
sexual endowment, which should be protected from all 
things that would ruin the home or produce defective 
offspring. That such an appeal makes a deep impression 
upon boys of high school age has been amply demonstrated 
during the showing of “Keeping Fit” exhibits in all parts of 
the country. This educational campaign is under way at 
the present time, on a stupendous scale, and we may hope 
to see the coming generation entering upon the experiences 
of life with its eyes open. 
However, even the best education will not always save a 
boy or girl from exposure to infection. Healthy bodies 
must have expression in one way or another. A part of 
the coordinated movement against venereal disease is that 
which is fostering more opportunities for wholesome play, 
for recreation that “blows off steam,” and that directs the 
mind into constructive channels, leaving no time or thought 
for sexual irregularities. Such provision is needful for 
the thousands of young men and women who go to our 
cities to make their way and who are forced to live in cheap 
boarding houses, often friendless and homesick, an easy 
prey to designing persons of the opposite sex. This was 
pointed out particularly by the New York investigators, 
but is true for all other cities. Equally urgent is the 
need of the small town and rural community. 
Medical prophylaxis and treatment are important phases 
of control, but are only makeshifts in the absence of 
“moral and educational prophylaxis.” Medical prophy- 
laxis has been used in the Army and Navy for sometime. 
However to be successful it is necessary that the man be 
willing to present himself for treatment within as short a 
time as possible after exposure. Figures from official reports 
indicate that infection is materially reduced where such is the THE VENEREAL DISEASES 
355 
case, but that the infection rate rises in direct ratio to the 
length of time elapsing between exposure and treatment. 
Treatment of the developed case in the infectious stage 
is necessary as a public health measure, in order to render the 
patient non-infective as rapidly as possible. This is 
particularly successful in syphilis, where one dose of 
arsphenamine will frequently accomplish the desired result. 
However, treatment until cured is essential in order to 
avert hereditary transmission of syphilis and to render a 
gonorrheic safe to his family. 
Unfortunately, there is too little appreciation on the 
part of the medical profession of the necessity for continued 
treatment. There is a tendency among some doctors to 
get all the money that can be squeezed from such a patient, 
which acts as a deterrent to proper treatment. Most 
victims of venereal infection are young men and women who 
can ill afford to pay high fees for long courses of medication, 
such as are essential to cure. When their money is gone 
they cease to call upon the physician, especially when there 
are no objective signs of disease. The profession can do 
much to diminish venereal infections by carefully studying 
modern methods of treatment, and by placing their fees 
within reasonable limits. 
On the other hand, ignorance leads many a patient to 
drop his treatment as soon as he can see no further signs of 
infection. Education, continuous and widespread, will 
remove this misunderstanding. Here again the physician 
can do much by making use of the literature that is readily 
available. Many states require that every physician 
treating a case of venereal infection shall hand to his patient 
the literature provided by the state department of health. 
For those who cannot pay medical fees, free clinics should 
be provided. The growth of such centers, many of them 
receiving federal aid, is phenomenal. 356 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
The patient himself should be under control of the health 
authorities, as would any other suffering with an infectious 
disease. In the case of venereal conditions, treatment 
renders the patient fairly safe to the public. So long as he 
continues treatment until cured, he is allowed to go about 
his business, in the majority of states. If, however, he fails 
to report to his physician for a given period, and the physi- 
cian has received no word of his employing another, the 
practice in many states is to require the physician last 
treating the case to report the patient’s name to the health 
authorities. The latter are then expected to find the 
patient and place him under restraint, if necessary, until 
cured. In most states public opinion is not sufficiently 
enlightened to permit of reporting all venereal disease cases 
by name, as yet. It is hoped that the day is fast approach- 
ing when this will no longer be true. 
It hardly seems necessary to add that concurrent dis- 
infection of all discharges and of articles soiled therewith 
must be practiced at all times. This is particularly neces- 
sary for doctors and nurses attending venereal disease cases. 
To sum up, then, let us bear in mind the principal points 
that have been made regarding the control of venereal 
infection: 
1. Suppression of prostitution 
2. A single standard of morals for men and women 
3. Education of young and old upon the real meaning of 
the sex function and upon its protection 
4. The setting of high ideals of love, marriage and 
parenthood 
5. Provision for wholesome recreation 
6. Early and continuous treatment of the infected 
7. Control of the patient. 
In conclusion, let it be urged that we approach the 
subject with open minds. Let neither prudish pharisaism 357 
WHOOPING COUGH 
nor maudlin sentimentality unbalance our thinking. We 
are faced with a “ condition, not a theory.” Let us give it 
the best we have of calm, reasoned, scientific analysis. 
41. WHOOPING COUGH 
Whooping cough takes rank second only to diphtheria as 
a cause of death from the communicable diseases, thereby 
refuting once more the popular fallacy that the so-called 
“ diseases of childhood” are harmless and should be acquired 
early. 
Infective Agent.—The Bordet-Gengou bacillus, or B. 
pertussis, has been indicted and proved guilty of producing 
this disease. It is found in immense numbers in the secre- 
tions of the bronchial tubes, particularly during the early 
stages of the infection. 
Immunity.—There is no natural immunity to whooping 
cough, although many observers believe a relative immu- 
nity exists during the first six months of life. Second 
attacks are quite rare. The results of prophylactic 
vaccination have been encouraging enough to warrant 
further tests on a larger scale and with heavier dosage. 
At least twice the ordinary dose should be used. 
Incubation Period.—Owing to the indefiniteness of early 
symptoms it has been difficult to determine the incubation 
period with exactness, but experimental evidence tends to 
place it at two weeks. 
Modes of Transmission.—Droplet infection doubtless 
plays the chief role in spreading whooping cough. In the 
early stage, when the bacteria are most numerous in 
the bronchial secretion, the case is most highly infective. 
So long, however, as the patient carries and distributes 
the organism, he is. more or less dangerous. This may 
continue for several weeks after the beginning of the 
spasmodic stage. 358 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
As in measles, the difficulty of diagnosing a case in the 
early catarrhal stage contributes to its dissemination. 
Moreover, there are many mild cases, among adults 
particularly, that are missed entirely and become foci of 
infection. 
Articles and hands soiled with the secretions may occa- 
sionally transfer the infection and it can be spread by 
kissing. 
Diagnosis.—The course of the disease is roughly divided 
into two stages—catarrhal and spasmodic. To distin- 
guish the former from other inflammatory processes of 
the respiratory tract is impossible, although such symptoms 
occurring in the presence of an outbreak of the disease 
should arouse suspicion and justify a provisional isolation. 
After a week or 10 days, the second stage develops, 
which is characterized by more or less frequent paroxysms, 
in which the patient continues to cough until breathless and 
ends the spell with a “crowing” inspiration. Vomiting 
may follow. The peculiar whoop is practically pathog- 
nomonic and, taken together with other symptoms, clinches 
the diagnosis. 
Methods of Control.—Promptly upon the development 
of suspicious symptoms, the patient should be isolated 
strictly, until the spasmodic stage is reached. For at least 
four weeks from that point, he should be excluded from con- 
tact with non-immunes and from frequenting places of 
public gathering. 
Concurrent disinfection of all discharges from the nose 
and mouth should be practiced, not overlooking the vomitus. 
Non-immune contacts must be quarantined for 14 days 
from last exposure and pet animals must be excluded, 
as they sometimes contract the disease. 
When a case develops in school, all children should be 
watched for early signs, resembling a common cold. Imme- YELLOW FEVER 
359 
diately upon the appearance of symptoms in a child he 
should be excluded, until sufficient time has elapsed for the 
spasmodic cough to develop. 
Mortality.—Emphasis must be laid upon the high mor- 
tality of whooping cough. Including sequelae, over one- 
fourth of all cases are fatal. This is partly due to the fact 
that many cases of tuberculosis in children are traceable 
to a prior attack of whooping cough. Sudden deaths from 
rupture of the heart and from cerebral hemorrhage are also 
quite common, in addition to complicating pneumonias. 
A feature of considerable significance, in this connection, 
is the fact that deaths occur more frequently among the 
younger victims of the infection, between the ages of six 
months and five years. Delaying the age incidence, there- 
fore, will materially reduce mortality and should be the 
principal aim of the health officer. 
42. YELLOW FEVER 
While yellow fever is unknown in the United States, at 
present, extensive outbreaks have occurred within quite 
recent times and its absence is wholly due to the watch- 
fulness of our quarantine authorities. To the south of us 
are many foci of the disease that are a constant menace to 
our shores. 
The control of this terror of the tropics is a monument to 
the heroism of a U. S. Army Commission composed of 
Reed, Carroll, Agramonte and Lazear. For these men 
risked their lives to prove the mode of transmission of the 
disease, by many attempts, and finally acquired the 
infection in the only way that it can be transmitted. One 
paid the supreme penalty as the result of his devotion to 
science. 
Infective Agent.—The specific organism has been sup- 
posed to be a filterable virus. Recently, however, Noguchi 360 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
appears to have isolated and identified it as a spirochaetal 
organism, the Leptospira icteroides. It will be interesting 
to note the further progress of his work in the near future. 
Incubation Period.—The period of incubation in man is 
five days. 
Immunity.—No natural immunity to yellow fever exists. 
Immunity for life is conferred by an attack of the disease. 
Children often suffer only lightly from the infection, which 
may even go unrecognized in them. 
Modes of Transmission.—Like malaria, the transmission 
of yellow fever depends entirely upon a mosquito. In this 
case aedes calopus is the culprit. This mosquito has 
alternating bands of black and white upon the legs; bites 
usually in the late afternoon, and is found almost entirely 
in the immediate vicinity of houses. Again the female is 
the vector of infection. 
Certain points established by the Army Commission 
should be noted. 
1. The blood of a yellow fever patient contains the 
infective agent for only three days after symptoms develop. 
2. When this blood is ingested by a mosquito, 12 days 
must elapse before another person can be infected. 
3. The mosquito remains infective for life, which is at 
least three months. 
4. The discharges of the patient are absolutely harmless. 
Diagnosis.—An isolated case of yellow fever may be 
difficult to diagnose. Bloody vomit and diarrhea, jaundice 
and profound prostration are salient features. When other 
cases in the neighborhood of an infected individual are 
found and Aedes calopus is present, diagnosis becomes easier. 
Methods of Control.—Control depends upon the screen- 
ing of the patient against mosquitoes and the eradication 
of the insects. In the case of yellow fever this is much 
simpler than with malaria, for the breeding places are YELLOW FEVER 
361 
right at hand and are not usually extensive. The same 
methods of drainage, filling, screening, oiling and the use 
of minnows apply. 
Further than preventing the entrance of mosquitoes in 
the sick room, for three days, no other precautions are 
necessary in the control of the patient. 
Mortality.—The mortality of yellow fever is high, 25 
to 30 per cent of cases dying. But we have a constant 
demonstration in many civilized countries that the mortality 
may be nil, if preventive measures are scientifically applied. PART III 
APPENDIX APPENDIX I 
PLAN OF COUNTY HEALTH WORK 
The following plan has been devised primarily for 
county health officers in order that they may so arrange for 
the carrying out of the details of their work as to give the 
most satisfactory results for the expenditure of funds and 
time available. 
1. Education. 
One of the primary duties of the local health department 
is to educate the people of the community as to the causes 
and prevention of the spread of communicable diseases, and 
as to the possibilities for community health improvement. 
In the attainment of this object, the health officer should 
(a) Provide a number of carefully considered addresses, 
using, where desirable, illustrations with lantern slides, 
charts and models and films. 
(b) Furnish to the people, with the aid of the state 
health agency and other public health agencies, such educa- 
tional material in the form of folders, pamphlets, bulletins, 
etc., as will prove of value in emphasizing the importance of 
health conservation. 
(c) Arrange, through the local press, for the publication 
of suitable news items and educational material relating to 
the work of the health department. 
(d) Give at community fairs and public schools, and at 
such other places as may be practicable, suitable public 
health lectures and exhibits. 
(e) Inform the people, especially teachers and school 
children, as to the health laws and regulations and the 
necessity therefor. 
365 366 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
(f) Make use of all other educational measures available 
for interesting and informing the people as to the impor- 
tance of public health protection. 
In the execution of the above plans, the health officer 
should enlist the support and cooperation of all available 
organizations and agencies. 
2. Control of Communicable Diseases. 
(a) Stimulate the prompt and complete reporting of 
cases of notifiable diseases on the part of physicians and the 
general public, through education, checking of newspaper 
notices, and investigation of verbal reports of suspected 
cases. Report card forms may be placed in convenient 
places within the county, especially in the schools. Special 
emphasis should be laid upon the reporting of suspected 
cases. 
(b) Visit, in person or by agent, homes, schools and 
communities, for epidemiological investigations, and the 
establishment of measures for the control of cases or 
suspected cases, or of outbreaks of communicable disease. 
(c) Keep a spot map showing the current prevalence of 
communicable diseases. 
(d) Make such laboratory examinations for the protec- 
tion of the public health, and for the diagnosis of communi- 
cable diseases, as may be requested, and maintain laboratory 
facilities, or a supply of shipping cases for specimens, 
supplied by the state public health laboratory for this 
purpose. 
(e) Consult with attending physicians relative to cases 
of communicable disease when requested, or wherever 
there may be difference of opinion as to the diagnosis of 
cases or suspected cases of communicable disease. 
(f) Arrange for free clinics as far as practicable, for the 
diagnosis of communicable diseases, and for the treatment of 
venereal diseases. (With the possible exception of venereal PLAN OF COUNTY HEALTH WORK 
367 
diseases, cases of communicable disease found should be 
referred to the family physician, or if unable to pay, to the 
city or county physician.) The health officer should 
avail himself of the voluntary services of physicians and 
others, where necessary, for the organization of such 
clinics. 
(g) Arrange to meet the people of the county, in the 
office of the health department or in publicly announced dis- 
pensaries at other places, for the purpose of administering 
vaccines or other protective biological products of estab- 
lished value. 
(h) Vaccinate, or supervise the vaccination, against 
smallpox, of all school children, or other children whose 
parents may request such vaccination. 
(i) Maintain a suitable supply, under proper conditions, 
of vaccines and anitoxins for use in emergency. 
(j) Report cases of notifiable disease promptly to the 
state health agency. 
3. Excreta Disposal. 
(a) Make, or cause to be made, an inspection of every 
home in the county, for the purpose of ascertaining the 
status of excreta disposal conditions and improving such 
conditions where necessary. Such work should be carried 
on in the more thickly settled communities first. In the 
rural sections, advice and persuasion should constitute the 
primary method of procedure. In incorporated villages, 
towns and cities the health officer should endeavor to secure 
suitable ordinances requiring the sanitary disposal of 
excreta, and to see that the provisions of such ordinances 
are carried out. 
(b) Prevent the pollution of streams. 
(c) Problems of municipal sewerage and sewage disposal 
should be referred by the county health officer to the state 
health agency for advice and instructions, where any 368 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
expenditure of municipal funds is involved, before taking 
any action. 
4. Water Supplies. 
(a) Make such inspections and laboratory examinations 
as may be necessary to keep informed as to the safety for 
consumption of all public water supplies. 
(b) Make, or cause to be made, an inspection of every 
private water supply within the county, and endeavor to 
secure, primarily through advice and persuasion, such 
improvements as may be necessary to make such water 
supplies safe for consumption. 
(c) Problems of municipal water supply involving an 
expenditure of municipal funds should be referred by the 
county health officer to the state health agency before 
taking any action. 
5. General Sanitation. 
(a) Advise the authorities of cities, towns and villages as 
to the most suitable methods of collection and disposal of 
manure, garbage and other wastes, and endeavor to secure 
proper ordinances for the regulation of the disposal of such 
wastes. The health officer should confer with the state 
health agency before making any recommendations as to 
municipal wastes collection or disposal. 
(b) Advise householders in the rural sections as to the 
best methods of the disposal of wastes, as to screening, 
and as to the elimination of fly and mosquito-breeding 
places. 
(c) Inspect, or cause to be inspected, all public buildings, 
courthouses, city halls and jails, and advise the local 
governing authorities as to needs for sanitary improvement. 
(d) Inspect, or cause to be inspected, all public and 
private school buildings as often as may be necessary and 
advise the authorities of public and private schools as to 
sanitary improvements needed in school buildings. PLAN OF COUNTY HEALTH WORK 
369 
(e) The health officer should enforce regulations or laws 
prohibiting common drinking cups and common towels, 
giving especial attention to public buildings, schools, 
hotels and restaurants. 
(f) The health officer should enforce regulations or laws 
governing the sanitation of swimming pools, labor camps, 
public camp grounds, sanitation of public buildings, etc. 
(g) In counties where there are National Forests, the 
health officer should cooperate with the Forest Supervisor 
and the Forest Rangers in the enforcement of sanitary- 
regulations, especially on recreation areas. 
6. Child Hygiene. 
Where there are one or more public health nurses on the 
staff, the work to be carried on under this heading should 
consist of the following. 
(a) The organization and instruction, by lectures and 
demonstrations, of mothers’ clubs and other groups of 
people in the essentials of home sanitation, prenatal and 
post-natal care, and especially in the feeding of infants, in 
accordance with a course of lectures approved by the state 
health agency. In connection with these clubs, there 
should be made, in accordance with forms and instruc- 
tions approved by the state health agency, physical exami- 
nations and records of the children of the community who 
are brought in by their mothers for examination and 
advice. In this way, mothers’ clubs will be utilized to 
develop a more intelligent and closer oversight of children 
by parents. 
(b) The keeping, where practicable, of a tack map of the 
county showing: 
1. breast-fed children, 
2. bottle-fed children, 
3. children under two years of age suffering from digestive 
disturbances or diarrheal diseases. 370 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
(c) Visits and conferences with parents in as many homes 
as possible where there are “2” and “3” in (b) above. 
(d) Provision at the office at the county seat, and at 
other appointed places, for conference with expectant 
mothers. These conferences may embrace, among other 
things, the simpler tests of urinary analysis and pelvimetric 
measurements, where practicable. Any important infor- 
mation elicited in these conferences shall be reported on 
regularly prescribed forms, with the permission of the 
expectant mother, to the family physician. 
(e) The organization and instruction of the midwives of 
the county, in such a way as to make the employment of 
midwives for obstetrical cases as safe as possible, and to 
insure prompt and accurate reporting of births by them. 
(f) Class instruction of midwives by a public health 
nurse, and individual instruction where advisable. 
(g) Enforcement of regulations or laws governing the 
practice of midwifery. 
(h) Enforcement of regulations or laws governing the 
prevention of infant blindness, and where funds are 
available, the supplying of free prophylactic (1% silver 
nitrate or an equivalent) to midwives, with instructions 
as to use. 
(i) Cooperation with school authorities, as far as is 
practicable, in the medical inspection and correction of 
defects of school children. 
Where such a plan is agreeable to both parties, it should 
be arranged with such authorities that the carrying out of 
the details of the work be placed under the supervision of 
the health officer. Under such an arrangement, where 
school nurses are available, all routine examinations are 
made by the nurses, such special examinations as may be 
needed being made by the health officer. No physical 
examination of any child should be made by the health PLAN OF COUNTY HEALTH WOEK 
371 
officer, or by any nurse under his direction, where the parents 
object to such examination. Records of examinations 
should be kept on standard cards meeting with the approval 
of'the state department of education and the state health 
agency. Parents should be notified in writing of defects 
found, and all cases should be referred, through the parents, 
to the family physician. As rapidly as possible, the nurses 
should follow-up defective children, for the purpose of 
ascertaining whether corrections have been made and urging 
attention to defects which have not been remedied, unless the 
physician consulted by the family has advised otherwise. 
No attempt should be made, under any circumstances, to 
force the correction of defects. If the defects have not been 
remedied as a result of poverty, such cases should be referred 
to the city or county physician, or to a free clinic, if 
available. No case should be referred directly to any 
particular physician. 
(j) The organizing of free clinics, where possible, through 
the voluntary cooperation of local physicians and dentists, 
for the correction of defects among indigent children. 
7. Sanitation of Foods. 
(a) Inspection of food-handling establishments and 
enforcement of adequate food sanitation regulations or laws. 
(b) The inspection and scoring of dairies and of milk- 
handling establishments, and bacteriological examinations 
of milk samples. 
8. Reports of Births and Deaths. 
(a) Receive reports of births and deaths; in some states, 
issue burial and removal permits, and file reports with the 
state health agency, in accordance with local practice. 
(b) Arrange for sub-registrars at convenient places out- 
side of the county seat; instruct them in their duties, and 
maintain adequate supervision over their work, if such is 
required by state law or regulation. 372 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
9. General Administration. 
All assistants should work under the direction of the 
health officer and perform such duties as he may assign. 
Travel should be done by automobile, except where 
such conveyance is unnecessary in cities, or where imprac- 
ticable. The cars should generally be provided by the 
employees and operating expenses be allowed. Expendi- 
tures of funds should be made by the health officer strictly 
in accordance with the approved budget, and strict account 
should be kept of all expenditures incurred, each item under 
its proper heading as outlined in the budget. 
10. Reports. 
Each health officer should prepare reports as follows: 
(a) A diary, giving resume of work of each day (for 
record only). 
(b) Monthly reports, not later than the 5th day of the 
succeeding month, for presentation to the local governing 
board. 
(c) Yearly reports, not later than the first day of 
February of the succeeding year. 
Monthly reports should be made on standardized 
statistical forms, and should include financial reports 
of the month’s expenditures, and a brief narrative report 
of the most important events. 
Special reports should be prepared as occasion demands. 
11. Cooperation with Other Agencies. 
The health officer should enlist the aid of all other agencies 
available, in carrying out his work, with special reference to 
city and county school authorities, home demonstration 
agents and county agricultural agents, supervisors and 
rangers of the Forest Service, the local chapter of the Red 
Cross, Women’s Clubs, Men’s clubs, and other organizations. 
The county health officer should endeavor to secure full 
cooperation on the part of the physicians of his county, by PLAN OF COUNTY HEALTH WORK 
373 
keeping them informed as to the progress of his work and by 
consulting with them freely upon all matters in which they 
may have a special interest. This should be done with the 
physicians as individuals and as a county medical society. 
The county health officer should be especially careful in the 
observance of the usual professional courtesies. He should 
keep constantly before the profession their peculiar duties 
as public servants, particularly in respect of making reports 
and other requirements of law or regulation. Such a 
spirit of cooperation should be fostered that a physician 
delinquent in these matters will be condemned by the united 
opinion of his professional colleagues. APPENDIX II 
A FORM OF STATISTICAL REPORT FOR LOCAL 
HEALTH OFFICERS 
The following report form has been in use, in one state, 
for about three years, and has been found quite satisfactory. 
It is made up on sheets 8.M X 11 in size. The same form 
can be used for summarizing the quarterly and annual 
statistical reports. 
Another state uses a more elaborate form than this, on 
which equivalent money values are given for each item. 
For instance, a visit to a case of communicable disease 
would be valued at one dollar, while the health officer, or 
nurse, would also be allowed a small amount for mileage. 
The total of these values really represents a score for the 
month’s work, which can be readily compared with that 
for other counties. There are, of course, flaws in any 
system of scoring, but it is useful for purposes of comparison, 
and also for making tangible to the public at least part of 
the value of the health department’s activities. A ot, 
any one can grasp a money value, even though he cannot 
visualize the same thing in terms of lives saved, or disease 
prevented. It is necessary in such a system that the 
public shall be convinced of the reasonableness of the 
equivalent values assigned to the items. In fact, they 
should be most conservative, in order to avoid any possible 
criticism of being placed too high. 
374 REPORT FOR LOCAL HEALTH OFFICERS 
375 
COUNTY OF 
COUNTY HEALTH OFFICER’S REPORT FOR MONTH OF 19. . 
(Include report of activities of all persons under your direction) 
I. EDUCATIONAL. 
1. No. public meetings addressed Attendance 
2. No. school talks given Attendance 
3. No. press articles published 4. No. office calls 
5. No. circular letters sent 6. No. pamphlets distributed 
II. COMMUNICABLE DISEASE CONTROL. 
1. Inspections for diagnosis ; Control ; Release 
2. Visits by nurse for communicable disease control 
3. Smallpox vaccinations: (1) Vaccinias. .. .; (2) Vaccinoids 
(3) Immunity reactions ; (4) No results 
4. Typhoid vaccinations: First ; Second ; Third 
5. Immunizing antitoxin—Doses 
6. Toxin-antitoxin: First ; Second ; Third 
7. Other prophylactic treatments (state kind and number of each).. . 
8. Venerea] Disease Control Measures: 
Cases investigated: Gonorrhea ; Syphilis 
Cases treated in clinic: Gonorrhea ; Syphilis • 
Special action on venereal disease cases: 
Month 
Diph- 
theria 
Meas- 
les 
Scar- 
let 
fever 
Small- 
pox 
Tuber- 
cu- 
losis 
Ty- 
phoid 
Per- 
tus- 
sis 
Cases on hand begin- 
ning of month 
CASES REPORTED. 
Cases released 
Cases died 
Cases on hand at end 
of month 
CASE RECORD: 
III. WATER SUPPLIES. 
1. Number of water supplies inspected: urban ; rural 
2. Number of water supplies unsafe: urban ; rural 
3. Number of water supplies improved: urban ; rural 376 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
IV. PRENATAL, INFANT AND CHILD HYGIENE. 
1. Prenatal instructions given 
2. Infant care instructions given: In clinics ; at home 
3. Meetings Mothers’ Classes Attendance 
4. Midwives’ Classes instructed Attendance 
Midwives inspected and instructed individually 
5. School children examined (number) 
Total defects found No. children having defects 
Number of children having defects corrected 
Number of follow-up visits 
6. Schools inspected for sanitation 
Violations school sanitation regulations found.. . .; corrected.... 
V. EXCRETA DISPOSAL. 
1. Number new privies constructed: urban.rural 
2. Number of privies repaired: urban ; rural 
3. Number of sewage disposal plants constructed 
4. Number of school sanitary privies constructed 
5. Number of sewer connections made 
VI. GENERAL SANITATION. (Except water, schools, excreta, food.) 
1. Number of new inspections ; reinspections 
2. Number of complaints investigated 
3. Number of fly-breeding nuisances abated 
4. Number of mosquito-breeding places abated 
5. Number of other nuisances abated 
VII. FOOD SANITATION. 
1. No. inspections (market, store, cafe and soda fountains) 
2. No. violations food san. regulations found ; abated 
3. No. dairy inspections No. dairies scored 
Number scoring above 90. ...; 81-90....; 71-80....; 61-70 
4. Number food handlers given physical examination 
Number food handlers rejected on physical examination 
VIII. LABORATORY. (Counties having own laboratories will render special 
report in addition to this report.) 
SPECIMENS SENT TO THE STATE PUBLIC HEALTH 
LABORATORY 
1. Diphtheria—diagnosis— positive negative 
release— positive negative 
2. Sputum, tuberculosis— positive netative 
3. Widals, typhoid— positive negative 
4. Blood cultures, typhoid— positive negative 
5. Feces and urine, typhoid— positive negative 
6. Smears, gonococcus— positive negative 
7. Wassermann, syphilis— positive negative 
8. Miscellaneous— REPORT FOR LOCAL HEALTH OFFICERS 
377 
IX. ADMINISTRATION. 
1. Personnel—Days worked: Health officer ; clerk 
Sanitary inspectors ; nurses 
2. Travel—miles: Health Officer ; nurses 
sanitary inspectors 
3. Letters received Letters answered 
4. Conferences with county, state or other officials (state person, 
office, date, place, purpose and decision) 
5. Legal actions taken (state cause, court and result) 
6. FINANCIAL STATEMENT. 
Item 
Budget 
Amount 
on hand 
first of 
month 
Expense 
this 
month 
Amount 
on hand 
end of 
month 
Salary H. 0 
Salary clerk 
Salaries nurses 
Salaries inspectors 
Transportation H. 0 
Transportation nurses 
Transportation inspectors. 
Vaccines, antitoxins 
Laboratory 
Office expense 
Miscellaneous expense 
B & D registration 
TOTAL BUDGETED.... 
Non-budgeted expense 
REMARKS: (Give a brief narrative of important events during the 
month and of matters not included in the foregoing statistical and financial 
tabulations, using the reverse hereof, and additional sheets if necessary 
to make an adequate presentation of the work accomplished.) 
Respectfully submitted 
19 
County Health Officer APPENDIX III 
INSTRUCTIONS FOR PUBLIC HEALTH NURSES 
The following outline is intended to suggest the kind of 
work and methods to be pursued by a public health nurse 
in a small organization. It makes no pretense to complete- 
ness, but may help the health officer to formulate a pre- 
liminary plan of nursing service. He can best improve 
upon this plan by taking the nurse into consultation and 
profiting from her experience. 
I. DIRECTION. 
A. When the salary and transportation of the nurse are 
paid entirely from county or municipal health funds, she 
shall work entirely under the direction of the health 
officer. 
B. When the salary and transportation of the nurse are 
paid in part by other local funds, the agencies furnishing 
these funds may be proportionately represented on a local 
nursing committee, of which the health officer shall be a 
member, and this committee may direct the nursing service. 
In case Red Cross funds are contributed for public health 
nursing service, it is obligatory that a nursing committee 
be organized. 
II. REPORTS. 
A. When the nurse’s salary and transportation are paid 
in full by county or municipal health funds, the nurse shall 
submit to the health officer monthly reports in duplicate, 
378 INTRUCTIONS FOR PUBLIC HEALTH NURSES 
379 
on approved forms. One of these reports shall be retained 
by the county health officer and the other sent to the state 
agency supervising public health nurses. 
B. When the nurse’s salary and transportation are paid 
in part by local funds, other than Red Cross funds, the 
monthly report fornj shall be made out in duplicate, one 
copy given to the chairman of the nursing committee, if 
there be one, and the other sent to the state agency super- 
vising public health nursing. 
C. When the nurse’s salary and transportation are paid 
in whole, or in part, by local Red Cross chapter funds, 
the nurse shall submit monthly report forms to the Red 
Cross, according to instructions from the Division Head- 
quarters of the American Red Cross. 
D. All monthly reports must reach their destination 
by the tenth of the following month. 
III. RECORD FORMS. 
A. Records for prenatal and infant hygiene nursing can 
be secured with family folder (social history) by ordering 
No. 5F (specifying as enclosures prenatal and child welfare 
cards) from Mead, Wheeler & Co., 3558 Wabash Avenue, 
Chicago, Illinois. 
B. Records for school nursing comprise the United 
States Public Health Service card entitled “Physical 
Examination of School Children” and “Parents’ Notifi- 
cation Card.” 
IV. DUTIES OF COUNTY PUBLIC HEALTH NURSE 
A. Communicable Diseases. (See state or local regula- 
tions for the Control of Communicable Diseases.) 
1. Follow-up of cases reported to the health officer, 
(a) To give bedside nursing demonstration 
(only after consulting attending private 
physician) 380 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
(b) To instruct a responsible member of the 
family or attendant or patient in: 
(1) Isolation of patient 
(2) Care of articles contaminated with 
discharges from patient 
(a) Dishes, etc. 
(b) Linen and clothing 
(c) Bedpans and urinals 
(d) Toys 
(3) Care of attendant’s hands 
(4) Proper disinfection and disposal of 
patient’s discharges and excreta 
(5) Protection from flies 
(6) Quarantine (or immunization) of con- 
tacts 
(7) Terminal disinfection (care of walls, 
floors, bedding and bed) 
2. If cases with suspicious symptoms are located 
by the nurse, she shall report the same to the 
health officer for his investigation. 
B. Infant Hygiene. 
Instructing mothers at home or in a class. 
No nursing care nor feeding instructions to be 
given without first consulting the attending 
physician. 
1. Demonstration of baby’s bath 
2. Clothing (exhibit model layette and patterns 
for same) 
3. Feeding 
(a) Breast milk 
(b) Care of breasts 
(c) Necessity of modification of cow’s milk 
for artificial feeding 
(d) Care of milk, nipples and bottles INSTRUCTIONS FOR PUBLIC HEALTH NURSES 
381 
(e) Importance of enough safe drinking water 
(f) How to make barley water 
4. Excreta 
(a) Normal and abnormal urine 
(b) Normal and abnormal stools 
(c) Care of diapers (covered pail) 
5. Importance of sufficient sleep 
6. Importance of sufficient fresh air 
7. Importance of protection from flies 
C. Prenatal Instruction. 
1. If the patient has a physician, consult him before 
advising patient. If the patient has no phy- 
sician urge her to consult one so that she may 
secure a complete physical examination and 
make arrangements as soon as possible for phy- 
sician’s attendance at delivery. 
2. If the patient insists upon employing a mid- 
wife, urge her to secure one who has been 
properly instructed. Give patient detailed 
instructions as to prenatal care, and secure, if 
possible, a specimen of her urine for examination 
by health officer. If possiffie have health 
officer make a physicial examination. 
3. Points to be stressed in prenatal instruction 
(a) Necessity of medical examination early in 
pregnancy 
(b) Clothing 
(c) Diet 
(d) Exercise 
(e) Care of bowels 
(f) Care of teeth 
(g) Care of breasts 
(h) Prompt reporting to doctor or nurse of 
danger signals 382 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
(i) Preparation and sterilization of articles for 
mother’s delivery and preparation of baby’s 
layette 
(j) Preparation of room for delivery (separate 
bed, clean linen, newspaper pads, sufficient 
sterile water—hot and cold) 
(k) Preparation of mother immediately before 
delivery (clean clothes, hair braided in 
two braids, enema) 
D. Instruction of Midwives. 
Whenever possible, midwives should be instructed 
in a class of not over 15 in accordance with an 
approved course of lectures and demonstrations. 
E. School Nursing 
In the absence of a special school nurse and with 
the approval of the local school boards, the 
county nurse should undertake this branch of 
the work. 
1. Routine individual examination of school chil- 
dren in rural and town schools shall be made 
once a year. 
2. Where the nurse has only town schools, a 
thorough classroom examination should also 
be made after each vacation (September, 
January, spring vacation). 
3. The nurse should consult with the county 
health officer and the superintendent of 
schools in formulating all plans for medical 
inspection of school children. After her rou- 
tine inspection of the school children, she 
should refer cases which need a special 
examination to the acting school physician 
or health officer, and a notification card, 
recommending the correction of the defects INSTRUCTIONS FOR PUBLIC HEALTH NURSES 
383 
by the child’s family physician or dentist, 
should be sent to the parents. 
4. Routine notification by card or visit should be 
made to the parents of all children having 
defects: (a) if diagnosis is made by physician 
or dentist, notice should state nature of 
condition; (b) if no physician sees case, 
the nurse should notify parents of apparent 
condition needing diagnosis by physician or 
dentist (never make a statement that might he 
construed as a diagnosis); (c) in cases requiring 
immediate attention, or when parents are 
likely to be antagonized by notification card, 
a visit should be made to the home as soon 
as possible. 
5. First visit to school 
Always precede first inspection by a general 
health talk, suiting the content to the age 
of children addressed. By this method the 
nurse can inform both the teacher and 
the pupils of what her plans are regarding 
examination of pupils and what she hopes to 
accomplish. 
6. Routine classroom inspections 
The nurse takes position by the window and 
requests pupils to stand, one row at a time, 
roll sleeves above elbows and file past, one 
at a time, while she notes general appearance, 
condition of skin, hair, eyes and oral cavity. 
(a) Try to avoid touching children. By train- 
ing them to pull down lower eyelid, 
signs of inflammation may be detected 
and, by having them lift up hair back of 
ears, pediculi may usually be seen. 384 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
(b) Place a supply of tongue blades on clean 
sheet of paper and drop blade used, 
after each mouth and throat examination, 
into a paper bag or funnel. See that 
these are burned before leaving school. 
Check up each case of adenoids, defective 
vision, tonsils and teeth, as soon as pos- 
sible after routine inspection. 
7. Points to be observed in making individual 
examination and in reporting defects: 
(a) EYES 
(1) Vision—Report vision as “defective” 
where pupil is unable to read correctly 
the 30-foot line at 20 feet, testing 
each eye separately. DO NOT 
REPORT vision defective if child can 
read 30-foot line at 20 feet and has 
no symptom of eye strain. Use Snel- 
len’s literate eye chart for children 
knowing letters. Snellen’s eye chart 
for children not knowing the alpha- 
bet can be secured from several 
manufacturers. 
(#) Other symptoms—crossed eyes, dis- 
charge, granulated eyelids or styes, 
ingrown lashes. 
(b) EARS 
To be done only in a quiet place away from 
the class room. Report defective hearing 
when pupil is unable to hear whispered 
conversation at a distance of from 15 
to 20 feet. Record “unable to hear whis- 
per at 20 feet.” Report all discharging 
ears. INSTRUCTIONS FOR PUBLIC HEALTH NURSES 
385 
(c) NOSE 
Report obvious cases of nasal obstruction 
in one or both nostrils such as might 
occur with deviated septum, polypi, etc. 
Have the pupil press finger on alternate 
nostrils and breathe with mouth closed. 
REPORT mouth breathers with charac- 
teristic adenoid facies. 
(d) THROAT 
Report all cases of enlarged tonsils with 
histories of recurrent tonsilitis or where 
the size of the tonsils causes difficulty in 
swallowing or thickened speech. Do 
not report other enlarged tonsils unless 
obviously diseased. 
(e) TEETH 
Report all teeth which are decayed. Report 
reddened and inflamed gums, crooked 
teeth, marked protrusion of upper teeth, 
offensive breath, and defects of mouth 
formation. 
(f) GLANDS 
Report glandular enlargement, especially 
when accompanied by evidence of mal- 
nutrition and anemia. 
(g) MENTAL RETARDATION 
Report cases of apparent defective mental 
development for further investigation. 
DO NOT REPORT as mentally defec- 
tive one who is backward on account of 
recent illness, poor physical condition, 
ignorance of English, or continued absence 
from school. 386 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
(h) WEIGHT AND MEASUREMENT 
In town schools, children should be weighed 
monthly. In rural schools, children should 
be weighed once a year. Have children 
remove shoes and coat before weighing 
or measuring. 
WEIGHT. If possible, secure a non-spring 
scale. 
HEIGHT. Record in inches. 
(i) PEDICULOSIS 
Exclude for one day. Talk to children 
privately about necessity of having clean 
head. Give note and written instructions 
to be taken to parent. If, on the follow- 
ing visit, nothing has been done, make 
home call and give demonstration. 
Always secure parent's consent before apply- 
ing treatment for pediculosis. Use much 
tact in approaching this subject. 
(j) VACCINATION 
Report to school superintendent all children 
who do not present a doctor’s certificate 
of successful vaccination, if there is 
no evidence of successful vaccination. 
Make similar report to the health officer. 
(This depends upon local or state vacci- 
nation laws.) 
8. Records 
(a) A medical inspection card should be made 
for each child and these should be filed 
in the nurse’s office. If the rural school 
cards are used for other members of 
the family, the school cards should be 
filed in the regular family folder referred INSTRUCTIONS FOR PUBLIC HEALTH NURSES 
387 
to under III, Record Forms. Through 
the superintendent’s office secure—• 
(.1) Names of children who have moved with- 
in the county. Record change of home 
and school address on medical record. 
(2) Names of children whose scholarship 
records • are to be transferred with 
the child to a school outside the 
county. Give superintendent a copy 
of medical record to accompany other 
records. 
(b) All defects should be noted concisely 
(c) Urgent defects should be underlined 
(d) After a defect has been corrected, record 
the date of correction in space provided 
(e) If the family physician, after examining the 
child, reports the recommended correc- 
tion of the defect unnecessary, note the 
case as closed and record a complete 
examination of the same, together with 
reason for closing. 
(f) Record date of home visit in space provided 
9. Health Instruction 
(a) Health Talks 
The nurse shall confer with the superinten- 
dent or school principal in regard to 
health talks. She could keep in touch with 
the teacher’s schedule on Health Instruc- 
tion, and follow up with talks emphasizing 
important points, varying health talks 
with grade visits. The following sub- 
jects should be covered: 
(.1) Fresh air—need for it at night as well 
as day 388 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
(2) Proper amount of rest 
(3) What, and what not, to eat, stressing 
the value of milk and water, the danger 
of too much tea and coffee 
(4) Mastication of food 
(5) Correct posture and necessity for deep 
breathing 
(i6) Care of the body—special care of hair, 
nails and teeth 
(7) Prevention of colds (infectious) 
(8) Proper use of handkerchief (sneezing 
and coughing) 
(9) Washing hands, especially before meals 
(10) Danger of putting articles in mouth 
and biting fingernails 
(11) Proper clothing—clothing to be suited 
to changes in temperature, need for 
frequent changes of clothing, stress- 
ing need for buttons, hooks, eyes, and 
shoe laces in their proper places. 
(12) Meaning of quarantine and isolation 
(upper grades) 
(13) Proper protection of feet—stress use 
of rubbers and changing wet shoes 
and stockings 
(b) Health Drills (Children should go through 
actual procedure with necessary acces- 
sories, and not depend upon pant- 
omime) 
(l) Toothbrush Drill 
(a) Keep record of number of pupils in 
class having toothbrushes at time 
of first drill and number who have 
brushes at time of last drill. INSTRUCTIONS FOR PUBLIC HEALTH NURSES 
389 
(6) Generally confine to first, second 
and third grades 
(c) Instruct children to keep tooth- 
brushes wrapped in clean whitepaper 
or envelope when bringing them to 
school for drill 
Note.—Some manufacturers will 
send sample tubes of paste upon request. 
Toothbrushes may be purchased by 
the gross at about 5 cents each. 
(#) Handkerchief Drill (confine to kinder- 
garden and first and second grades) 
(3) Handwashing Drill 
Emphasize washing before meals 
10. Contact with Teachers 
Before visiting a school, it is well to notify 
the teacher of the approximate date of the 
nurse’s visit. Before leaving school, be sure 
the teacher has a copy of the chart giving 
symptoms of communicable diseases, obtain- 
able from the state health agency. Also 
confer with him regarding the obvious symp- 
toms of physical defects, such as— 
(a) Pupils not seeing well 
(b) Pupils not hearing well 
(c) Pupils complaining of headaches, particu- 
larly at the latter part of the day 
(d) Pupils complaining of toothache 
(e) Pupils breathing with open mouths 
(f) Pupils asking to leave the room too frequently 
(g) Pupils having habitual colds 
11. Contact with Parents 
If practicable, the teacher may ask parents to 
be present when the nurse visits the school. 390 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
The nurse should inform parents of a regular 
hour for consultation at her office. If there 
is a Parent-Teachers’ Association, use every 
opportunity of explaining the aims of the 
work to them. 
12. Follow-up Calls 
(a) To learn why defect has not been corrected 
(b) To urge and persuade the correction if it 
has been neglected through carelessness, 
prejudice or ignorance 
(c) To learn the financial condition of the parent, 
if he claims that he is unable to pay for a 
physician to examine and correct his 
child’s defect 
(d) To demonstrate— 
(.1) Treatment for Pediculosis. Mix thor- 
oughly equal parts of kerosene oil 
and vinegar. Saturate hair and cover 
the head with a towel, for at least 
H hour. Then remove towel and 
comb hair thoroughly with fine tooth 
comb. Finally, wash with plenty 
of hot water and toilet soap. Rinse 
well and dry the head thoroughly. 
(2) Ventilation of sleeping rooms 
(5) Bath, if no facilities are available at 
school 
13. Arrangements for correction of defects for 
children of parents who are unable to pay 
(a) If, after a thorough investigation of the 
parent’s financial condition, the nurse 
believes that he is unable to pay, she 
should arrange to send the child to the 
physician for the poor, for treatment of 
minor ailments. INSTRUCTIONS FOR PUBLIC HEALTH NURSES 
391 
(b) Arrangements for special treatment, such 
as operations, refractions, etc. The nurse 
in cooperation with the county health 
officer and local physicians and dentists, 
should try to stimulate the formation of 
a clinic for the treatment of actual 
indigents (see instructions for nurse as 
to social technique for free clinic). 
14. Sanitary inspection of school buildings 
The nurse should make a sanitary inspection 
of all town school buildings at least once a 
month, and of all rural school buildings at 
least once a year. She should note in this 
inspection whether the buildings comply with 
the laws or regulations and report points of 
non-compliance to the health officer, or to the 
superintendent of schools having jurisdiction. 
In the latter case, reports should be made in 
a tactful manner, giving full explanation of 
why the irregularities need to be remedied. 
V. NURSING EQUIPMENT 
1. Visiting Nurse Bag 
2. Butchers’ aprons for bedside nursing demon- 
strations. Plain black or navy blue tailored 
hats are desirable, and if wash uniforms are 
worn, they should be tailor-made of plain 
. * blue, gray or white material. 
VI. NURSING TECHNIQUE 
A. Care of Hands. 
1. Scrub thoroughly with nail brush, soap and 
warm water before and after caring for the 
patient. After caring for a communicable 392 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
disease, clean nails with toothpicks, using 
fresh ones for each case. 
2. Surgeon’s gloves to be worn 
(a) In giving bedside care to scarlet fever or 
erysipelas 
(b) Sterile gloves in demonstrating a post- 
partum perineal dressing. 
B. Care of Apron after Communicable Disease 
Nursing. 
After scrubbing hands, fold apron right side in 
and place in paper bag. If left in patient’s 
room, direct family not to open. Return apron 
to office in bag and, after soaking in disinfectant, 
send to laundry. 
C. Disinfection of Thermometers. 
1. Before taking temperature, rinse thermometer 
in running water 
2. After taking temperature, scrub under running 
water with soap, wrap in piece of cotton 
saturated with 70% alcohol, leave 20 minutes. 
Whenever possible, induce cases of com- 
municable disease to purchase a thermometer 
for personal use. 
D. General Routine in House. 
1. Remove hat and coat, placing on chair away 
from the wall or bed. Place bag on a clean 
newspaper on a chair or table. If visiting a 
case of communicable disease, leave hat, 
coat and bag in outer room. 
2. Take everything needed for the visit from the 
bag before beginning work. 
3. Place articles taken from the bag either in an 
apron pocket or upon a piece of clean paper 
(preferably a paper towel). INSTRUCTIONS FOR PUBLIC HEALTH NURSES 
393 
4. If these articles have been handled after hands 
have been soiled with infective discharges 
from patient, scrub hands and disinfect 
articles before replacing them in bag. 
5. Visit maternity cases before communicable 
diseases, if possible. 
VII. STIMULATION AND CONDUCT OF CLINICS 
A. For Correction and Treatment of Defects. 
1. Indigent school children 
2. Indigent infants and pre-school children 
3. Communicable diseases, particularly of the 
skin and eyes, and for venereal infections. 
B. Technique in Clinic Organization and Management. 
1. After consultation with the health officer, the 
nurse should try to induce local physicians 
and dentists to cooperate in giving clinic 
service for the treatment of the above classes 
unable to pay the fee charged for a private 
case. 
2. Arrange for the social financial investigation of 
each patient applying to the clinic. All 
patients who, after such an investigation, 
are found able to pay for a private physician’s 
care should be excluded from the clinic. 
3. Before admitting an applicant to the clinic, 
learn by what local physician he, or members 
of his family, have been previously treated. 
Unless the case demands emergency care, 
delay admission of the applicant until he 
returns with a letter referring him to the 
clinic and signed by his family physician. 
4. Form Letter to be sent to the Family Physician 
of Applicant: 394 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Name of Clinic 
Date 
To Dr 
Mr has applied here for treatment for 
We are delaying the admission of this 
patient until we receive your signed approval on the form below. 
Director of Clinic 
Date 
To Clinic: 
I hereby refer Mr to Clinic 
for treatment for In my estimation he is 
unable to pay for adequate medical attention. 
(Signed) M.D. 
C. Organization of Prophylactic Infant and Child 
Hygiene Clinics. 
Clinics held for the weighing and measuring of 
infants and children and for advice concerning 
their proper feeding and care shall be open to 
all of the public, regardless of financial circum- 
stances. In cases of illness, the clinic physician 
or nurse should refer the parents to their private 
physician, or, if they are unable to pay, to the 
clinic for free treatment. 
VIII. PUBLICITY 
A. Newspapers. 
In consultation with the local health officer, the 
nurse should keep local newspapers supplied 
with interesting occurrences in her work, avoiding 
always the giving of information that might 
identify an individual case or family. 
B. Talks to Clubs, Churches, Parent-Teachers’ Asso- 
ciation. 
Whenever possible, the nurse should explain her 
program to the above organizations. 
C. Exhibits—Infant and Child Health Conferences. 
Material and advice for these can be secured from 
the state agency of health or child welfare. APPENDIX IV 
A PLAN OF ORGANIZATION FOR MEDICAL, 
NURSING AND RELIEF SERVICE FOR LOCAL 
COMMUNITIES, DURING EPIDEMICS 
COMMITTEES 
1. Central Committee. 
2. Finance Committee. 
3. Intelligence Committee. 
4. Medical Service Committee. 
5. Nursing Service Committee. 
6. Hospitalization Committee. 
7. Subsistence and Relief Committee 
8. Transportation Committee. 
9. Mortuary Committee. 
1. CENTRAL COMMITTEE. 
PURPOSE—To direct, coordinate and supervise the 
work of the various committees. 
DUTIES—(a) Organize a central committee consisting 
of the health officer, the principal Red Cross official, the 
mayor or chairman of the county commissioners and two 
others. 
(b) Appoint the chairmen of the other committees herein 
suggested, and to outline and supervise their work. 
(c) Meet daily for conference with chairmen of other 
committees, at 5 P.M. or other suitable hour. 
2. FINANCE COMMITTEE. 
PURPOSE—To provide the funds required for the entire 
organization, and disburse the same. 
395 396 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
DUTIES—(a) Provide method of financing through 
city or county authorities, the local or national Red Cross, 
or private subscription. 
(b) Disburse funds available on demand of chairmen of 
committees, after approval by central committee. 
3. INTELLIGENCE COMMITTEE. 
PURPOSE—To locate promptly cases of illness, and cases 
requiring subsistence, relief, medical or nursing service. 
DUTIES—(a) Provide a central clearing house in 
headquarters. Here all reports from field workers are to be 
received and referred to the proper committees. 
(b) District city or rural area into districts, with a cap- 
tain and ten lieutenants in each. Districts should be of 
such size (e.g. ten city blocks) that each lieutenant can 
cover his unit within one hour each morning. 
(c) Select a captain living in each district, who shall 
appoint and be responsible for his lieutenants living in each 
unit of the district. 
(d) Lieutenants are to canvass every house in unit the 
first thing each morning, rendering a report to the captain, 
by ten a.m., who in turn reports to chairman of committee 
at central clearing house by eleven a.m. 
(e) Chairman of committee segregates reports, and sends 
each report to the chairman of the proper committee of the 
organization. 
(f) A staff of special intelligence lieutenants is to be 
maintained at the central clearing house, to investigate at 
once special reports not received from district captains. 
4. MEDICAL SERVICE COMMITTEE. 
PURPOSES—To provide medical attention for all cases 
reported by intelligence committee, which cannot be 
hospitalized, and to provide the medical staff for emergency 
hospitals. A PLAN OF ORGANIZATION FOR MEDICAL SERVICE 
397 
DUTIES—(a) List all available physicians who will 
volunteer for public service, either whole or part time. 
(b) Assign volunteers, and physicians provided by the 
United States Public Health Service and the State Depart- 
ment of Health, to the emergency and other hospitals, and 
to cases in rotation, keeping a waiting list of patients. 
5. NURSING SERVICE COMMITTEE. 
PURPOSES—-To secure all available trained and practi- 
cal nurses in the community to head wards in hospitals 
and give instructions to volunteer nurses’ aids. To obtain 
nurses’ aids. 
DUTIES—(a) List all trained and practical nurses in 
the community. 
(b) Organize a corps of nurses’ aids, preferably women 
who have had First Aid or additional Red Cross courses. 
(c) Assign all nurses and nurses’ aids to hospitals and 
cases as required. All nurses and nurses’ aids are to report 
at once to chairman of committee on completion of case, 
for re-assignment. 
(d) Receive and act upon reports from chairman of 
intelligence committee, physicians, etc., as to need for 
nurses. 
6. HOSPITALIZATION COMMITTEE. 
PURPOSE—To provide hospital facilities and if neces- 
sary to secure location and equipment for, and install and 
manage, emergency hospitals. 
DUTIES—(a) List all available accommodations in exist- 
ing hospitals. 
(b) Keep hospital accommodation list up to date by 
checking out all deaths and recoveries. 
(c) As required, provide additional emergency hospital 
accommodations. 398 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
(d) Assign cases as required to hospitals, according to 
accommodations available. 
(e) Receive and act upon reports from chairman of 
intelligence committee, physicians, etc., as to cases requiring 
hospitalization. 
(f) Notify chairman of transportation committee to 
provide transportation of cases to and from hospitals. 
7. SUBSISTENCE AND RELIEF COMMITTEE. 
PURPOSE—To provide prepared food, or food supplies, 
fuel or other supplies to families and persons sick, as needed. 
DUTIES—(a) Receive reports from chairman of 
intelligence committee, physicians, etc., of cases requiring 
subsistence or relief. 
(b) Make special investigation of requests for subsis- 
tence or relief not received through organization channels, 
by means of special investigators; at least one such special 
investigator to be always on duty during the day. 
(c) Establish diet kitchen and commissary for disburse- 
ment of prepared food and supplies. 
(d) Organize personnel for preparation, issue and dis- 
tribution of food and supplies. 
(e) Requisition transportation for food and supplies from 
chairman of transportation committee. 
8. TRANSPORTATION COMMITTEE. 
PURPOSE—To provide system of transportation for 
physicians, nurses, relief, supplies, subsistence, intelli- 
gence, hospitalization, etc. 
DUTIES—(a) List all available automobiles, trucks, 
boys with bicycles, etc. 
(b) Receive requests for transportation from chairmen of 
other committees. 
(c) Assign available transportation service as required. A PLAN OF ORGANIZATION FOR MEDICAL SERVICE 
399 
9. MORTUARY COMMITTEE. 
PURPOSE—To see that adequate burial facilities are 
available to meet the emergency. 
DUTIES—(a) List all available burial and crematory 
facilities, and undertakers. 
(b) Provide and supervise edequate force of grave- 
diggers, undertakers’ assistants, etc, 
(c) Assign deaths to undertakers and burial grounds 
or crematories according to capacity. APPENDIX V 
LECTURE COURSE FOR MIDWIVES 
The following course of instruction is intended to be given 
by a trained nurse. It has been offered to women living 
in isolated rural communities, where medical attendance was 
lacking, irrespective of whether the students were midwives 
or not. 
LECTURE I 
Care of Baby 
1. Care of baby at birth 
(а) Grease child (clean lard or oil), especially head 
(б) Application of binder to secure cord dressing 
(c) First clothes—review of layette 
(id) Asphyxia—hold up by feet and spank until baby 
cries and breathes 
2. Demonstration of baby’s bath 
(а) Sponge until after cord is off. First bath three 
hours after birth (grease child before bathing) 
(б) Tub bath (hands supporting back of neck and 
head) after cord comes off. 
LECTURE II 
Care of Baby (Continued) 
1. Nourishment 
(а) Regularity of feeding 
(б) Method of giving water (lack of water shown by 
brick red stains on diaper) 
400 LECTURE COURSE FOR MIDWIVES 
401 
2. Sleep 
(a) Individual bed 
(b) Open windows (avoid draughts) 
(c) Regularity—18 to 22 hours 
3. Danger signals for baby 
L(a) Eyes—inflammation and discharge (report to 
physician) 
(6) Bleeding cord—(report to physician) 
(c) Convulsions—(report to physician) 
(d) Failure to nurse (report to physician) 
(e) Unusual jaundice (report to physician) 
(/) Failure to pass urine or feces after 24 hours (report 
to physician) 
LECTURE III 
Health in Home 
1. Personal hygiene 
Baths, clean clothes (especially when attending 
woman in or after confinement), separate drinking 
cups, towels, kissing, sneezing, coughing, spitting 
2. Cleanliness in kitchen 
(a) Boiling dishes 
(b) Proper disposal of garbage to avoid flies 
(c) Flies—fly trap 
3. Location of sick room 
Bed-making and care 
LECTURE IV 
Prenatal Care 
1. Pregnancy—simple explanation (illustrate with 
flowers) 
2. Instructions as to what prenatal mother should know 
(a) Diet 
(1) Plenty of water 
(2) Avoid overeating 402 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
(3) Avoid much meat 
(4) Drink plenty of milk—stress keeping cow for 
milking—care, feeding, etc. (for rural women) 
(5) Eat as much fruit and fresh vegetables as 
possible 
(b) Hygiene 
(1) Proper clothing (suspended from the shoulders) 
(2) Proper exercise (avoid lifting heavy things 
and using sewing machine with foot power) 
(3) Daily bowel movement (simple remedies for 
constipation—fresh or cooked fruit, senna, 
prunes, coarse cereals) 
(4) Bathing (avoid very hot or cold baths) 
(5) Fresh air 
(6) Rest—sleep alone, and rest twice daily for 
fifteen minutes 
(c) Care of breasts 
(1) Avoid pressure on breasts 
(2) Bathe daily with soap and water 
(3) Care of depressed nipples (massage) 
(d) Varicose veins (demonstration of bandaging) 
(e) Instructions mother should have about preparing 
for confinement 
(1) House supplies—patient’s bed—demonstrate 
making (linen and oil cloth) 
(2) Baby’s bed—box, drawer, or basket 
(3) Baby’s layette 
3. Need for medical attention 
(a) Headache, spots before the eyes, puffiness under 
the eyes, swelling of ankles, vaginal bleeding, 
much vomiting after third month (stress report- 
ing these to physician at once) 
(b) Need of testing the patient’s urine by a physician LECTURE COURSE FOR MIDWIVES 
403 
LECTURE V 
Bedside Care 
1. Immediate preparations before confinement 
(a) Clean clothes 
(b) Supplies out, but not open 
(c) Hot and cold water 
(d) Enema 
(e) Keep away from toilet after water breaks 
2. Bed bath—24 hours after confinement. Changing 
bed with patient in it. 
LECTURE VI 
Bedside Care (Continued) 
1. Perineal dressing 
2. Combing hair 
3. Diet after confinement 
(a) Liquids for first two days 
(b) Soft light diet on third day 
(c) Avoid much tea, coffee, meat and fried foods 
(d) Stress water, fruit and vegetables 
4. Care of bowels 
(а) Cathartic on forenoon of third day (ounce of 
castor oil followed by saline enema in six hours) 
(б) Daily bowel movement thereafter 
5. Applications of heat and cold 
(a) Flaxseed poultice 
(b) Mustard paste 
(c) Cold compress 
(d) Hot water bottle and substitutes 
LECTURE VII 
Review of all previous lessons and examination 404 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
LECTURE VIII 
(Special for Midwives) 
1. Bag equipment 
(a) Care to have listed articles and care of each 
(1) Clean apron 
(2) Cake of white soap (Ivory or Fairy) 
(3) Nail brush 
(4) Lysol 
(5) 2 clean towels wrapped in clean cloth 
(6) Clean lard or salad oil 
(7) Cord dressing and tape (might be furnished 
by county health department) 
(8) Pair scissors (blunt points) 
(9) Nitrate of silver 1 per cent, (might be furnished 
by country health department) 
(10) Absorbent cotton (in clean box or clean cloth) 
(11) Enema bag (if possible) 
(b) Care to have nothing superfluous (no other 
articles than described in the list) 
(c) Care of articles (all linen to be boiled between cases) 
(d) Reasons for carrying bag 
(e) Demonstrate scrubbing hands, making up lysol 
solution 
2. Immediate after-care of baby 
(а) Eyes 
(1) At birth, silver nitrate 1 per cent.'—two drops 
in each eye 
(2) Daily care, boracic acid solution, demonstrate 
separate swab for each eye (swabs burned 
after using) 
(б) Cord 
(1) At birth. Tie with sterile tape; avoid thread 
or string (why); cut with boiled scissors; LECTURE COURSE FOR MIDWIVES 
405 
apply sterile cord dressing (tape and cord 
dressing might be furnished by county 
health department), or substitute clean rag 
with hole burned in it 
(2) Proper procedure in changing dressing if it is 
soiled (umbilical infections). 
LECTURE IX 
Course of Labor 
(To be given, if possible, by a physician) 
1. First stage—up to sixteen hours (wide variation) 
(а) Pains in back, then front, recurring more fre- 
quently (this is usual, but not invariable) 
(б) Let patient walk, sit or lie down 
(c) Give enema 
(d) Urge liquids if labor is long 
2. Second stage—few minutes to two hours 
(a) Pains harder, more frequent, and, as a rule, 
bearing down 
(b) Rupture of bag of waters (normal, but not 
invariable) 
(c) Bulging of perineum 
(d) Protection of perineum (place hands on head of 
child with gentle force, allowing head to 
advance a little with each pain) 
(e) Escape of head 
(/) Delivery of shoulders and body 
(g) Cutting cord—technique 
(h) Asphyxia—treatment 
3. Third stage 
(a) Interval between birth of child and expulsion of 
placenta, one-half hour 406 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
(6) Never pull on cord to deliver placenta 
(1) Pulling interferes with normal contraction of 
placenta into a longitudinal roll. Causes it 
to spread out and block the mouth of the 
uterus 
(2) Danger of leaving pieces of the placenta in 
the uterus 
(3) Sometimes causes eversion of uterus 
(c) Gently knead abdomen, until the uterus hardens, 
and exert downward pressure 
(<d) If placenta is not delivered in one hour after birth, 
call a physician (meanwhile keep up pressure on 
fundus) 
4. Abnormal presentation—breech cases 
(a) Seize the feet of the child and lift them straight up 
over the mother’s abdomen until the mouth is 
exposed or reverse this process, depending on 
position of child 
(b) Traction by shoulders, or with fingers in child’s 
mouth 
5. Complications of labor—when to call a physician 
(а) Antepartum hemorrhage (placenta praevia) 
(б) Very frequent and hard pains with no progress 
apparent after 24 hours 
(c) Internal hemorrhage (patient weak, pale, chilly, or 
very thirsty, panting for breath) 
(d) Child’s hand down—transverse presentation 
(e) Water not breaking-pains frequent and patient 
frantic 
(/) Too hard or long labor—24 hours 
(g) Severe headache, blindness, convulsions 
(eclampsia) 
(h) Delay in twin births LECTURE COURSE FOR MIDWIVES 
407 
(i) Sudden cessation of pains, withdrawal of fetal 
head with or without bleeding—generally pros- 
tration (rupture of uterus) 
(j) Prolapsed cord (child may die) 
6. Review of safety rules 
LECTURE X 
Review and examination, if possible, with last lesson. APPENDIX VI 
A DAIRY SCORE CARD 
The following score card for dairies has been developed 
from that issued by the Bureau of Animal Industry, U. S. 
Department of Agriculture. It differs from the latter in 
that it lays more emphasis on methods than on equipment. 
While good equipment renders the production of clean 
milk much easier, nevertheless it is entirely possible to 
secure quite satisfactory milk with very meager equipment, 
provided the dairyman applies sanitary principles to such 
as he has. 
DETAILED DIRECTIONS FOR USING THE DAIRY SCORE CARD 
I. GENERAL INSTRUCTIONS 
1. STUDY these detailed instructions carefully, and 
have them well in mind before scoring a dairy. 
It is best to review them before commencing a 
series of scores, and to refer to them whenever 
in doubt. 
2. On scoring trips, always carry a folding three- 
foot rule, a reliable thermometer, a supply of 
score cards, and a copy of these directions. 
3. Before commencing to score, the inspector should 
look over the entire plant, and be familiar with 
the layout, the number of employees and their 
duties, the number of cowp, the times and 
sequences of operations, etc. Make a written 
record of all such information, and keep it on 
file in the office. 
408 A DAIRY SCORE CARD 
409 
Face of Dairy Score Card 
(Size m" X 934") 
NEW MEXICO STATE BUREAU OF PUBLIC HEALTH 
DAIRY FARM SCORE CARD 
(Modified from Standard Card of U. S. Bureau of Animal Industry) 
Score 
Score 
Equipment 
JCr Allowed 
Methods 
Per- 
Allowed 
feet 
feet 
COWS 
cows 
Clean (curried and brushed) 
(Free from visible dirt, 4) 
STABLES 
6 
6 
Health 
Apparently in good 
health 
1 
If tested with tuber- 
Walls H 
culin within a year 
and no tuberculo- 
sis is found, or if 
tested within six 
months and all 
Ceding and ledges... 1 
Mangers and parti- 
tions 1 
Windows 
Stable air at milking time... 
Freedom from dust.. 2 
3 
reacting animals 
5 
removed 
Freedom from odors. 1 
If tested within a year 
2 
and reacting animals 
are found and re- 
moved 
3 
Removal of manure daily to 
1 
STABLES 
MILK ROOM OR MILK 
HOUSE 
Location of stable 
1 
Cleanliness of milk room.... 
UTENSILS AND 
3 
Well drained 
hi 
Free from contami- 
MILKING 
nating surround- 
Care and cleanliness of 
ings 
M 
8 
Construction of stable. 
3 
Thoroughly washed.. 2 
Sterilized in steam for 15 
Tight, sound floor 
and proper gutter 
2 
minutes 3 
Proper stall, tie, and 
Placed over steam jet, 2; 
manger 
1 
scalded with boiling 
Provisions for light: 
water, 1. 
Four square feet of 
Protected from con- 
opening per cow... 
3 
11 
ing, 2; two square 
feet, 
Clean, dry hands.... 4 
1; one square foot 
of 
Udders washed and 
opening, >3; deduct for 
wiped 7 
uneven distribution.) 
(Udders cleaned with 
4 .... 
moist cloth, 4; cleaned 
with dry cloth or brush 
Ventilators in roof.., 
1 
Windows hinged at 
at least 15 minutes 
bottom 
1 
before milking, 1.) 410 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Score 
Score 
Equipment 
Per- 
fect 
Allowed 
Methods 
Per- 
fect 
Allowed 
(Sliding windows, 
0.5). 
Cubic feet of space 
per cow, 500 feet.. 2 
(Less than 500 feet, 1; less 
than 400 feet, ; less 
than 300 feet, 0.) 
HANDLING THE MILK 
Cleanliness of attendants in 
2 
Milk removed immedi- 
ately from stable with- 
out pouring from pail... 
Cooled immediately after 
1 
3 
> 
UTENSILS 
6 
Construction and condition 
1 
(51° to 55°, 4; 56° to 60°, 
2.) 
3 
1 
(51° to 55°, 2; 56° to 60°, 
1) 
Transportation below 50° F. 
(51° to 55°, 1.5; 56° to 
60°, 1.) 
(If delivered twice a day, 
allow perfect score for 
storage and transporta- 
tion.) 
EMPLOYEES 
(Clean, convenient and 
abundant.) 
2 
5 
4 
1 
MILK ROOM OR MILK 
HOUSE 
9 
Location; Free from con- 
taminating surroundings. . 
1 
Medical examination twice 
a year including labora- 
tory tests—new employ- 
ees examined before 
working 9 
Once a year, ditto 5 
Twice a year, except 
lab. tests 5 
Once a year, except lab. 
2 
Floor, walls, and 
ceiling 1 
Light, ventilation, 
screens 1 
Separate rooms for washing 
utensils and handling 
1 
2 
If new employees not exam- 
ined including lab. tests, 
deduct two-thirds of 
above. 
Steam sterilizing chest. 2 
Steam jet 1 
Boiling water 0.5 
Total 
35 
Total 
65 
Equipment + Methods = 
Final Score A DAIRY SCORE CARD 
411 
R. F. D. No 
County 
Permit No 
License No 
Milk 
Cream 
Number of cows 
Date of inspection 192.... 
Remarks: ' 
Bacteria counts 
Butter fat 
Sediment tests 
Approved: * 
Inspector. 
Health Officer. County Health Department. 
Reverse of Dairy Score Card 
Owner or Manager 
Post Office 
Trade name 
Number of wagons Gallons sold daily 412 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
4. IN DOUBTFUL CASES, the doubt shall be 
resolved against the dairyman. No credit shall 
be given unless fully and clearly earned. Never 
give the dairyman the benefit of the doubt, as 
this removes both stimulus to improvement and 
incentive to improve his score. 
5. DO NOT GUESS.-—Have definite, personal infor- 
mation on each and every point. Personally 
inspect and check the tuberculin tests, identi- 
fying each cow with its test record. Personally 
identify each employee with his medical cer- 
tificate. Examine every detail of operations, 
each piece of equipment, in person: do not take 
any person’s word for anything, if it is possible 
for you to verify it yourself. Measure carefully 
barns, windows, etc., and record the measure- 
ments on the back of the card, at all first 
scorings, and whenever changes are made. 
Personally take the milk temperatures and 
record them on the back of the card. 
6. When you have completed the scoring, look the card 
over again carefully, re-check any point as to 
which there is the slightest doubt. Do not give 
the dairyman a copy of the score at the time 
of inspection. After you have returned to the 
office, send him a copy with a letter giving det ailed 
instructions as to how he can improve his score. 
7. NEVER GET INTO AN ARGUMENT with a 
dairyman about his score. Be courteous, 
answer his questions, give him whatever expla- 
nations or information he may need, be firm, 
but do not argue. 
8. Do not let the dairymen have advance information 
of dates and times of inspections. It is best to A DAIRY SCORE CARD 
413 
score at the morning milking, returning for the 
evening milking if necessary to complete the 
score. 
9. It is advisable to publish the relative scores from 
time to time in local newspapers. List the 
dairies in the order of their scores, putting the 
highest score first. 
II. EQUIPMENT 
10. COWS. Health.—Cut off 0.1 for each cow in a 
string of twenty or less, or for each two cows in 
a herd of 40, or for each three cows in a herd of 
60, that have any defect of health. In case of 
open abscesses, retained after-birth, garget or 
inflamed udders, etc., cut off 0.5 or more and 
order cow removed from milking string. 
11. COWS. Tuberculin Test.—If entire herd, includ- 
ing bulls, is not tested, give no credit under this 
item, unless omitted animals are dry stock on 
range and not to be returned to milking string 
unless first tested and passed. If new animals 
are purchased and added to the milking string 
without first passing the tuberculin test, allow 
no credit under this item. 
12. STABLES. Location of Stables.—Well drained 
into a sub-surface irrigation system or covered 
cesspool, give 0.5. When sufficient and proper 
absorbent is placed in gutters to absorb all 
urine, give 0.3; well-kept open flumes, give 0.2. 
When corral is next to milking barn give 0.3; 
if adjacent area or corral is dusty, allow no 
credit. If open privy within 200 feet, deduct 
5.0 from total score, and allow no credit under 
“Free from contaminating surroundings”; if 414 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
open privy within 100 feet, allow no credit as 
above, and deduct 10.0 from total score. 
13. STABLES. Construction of Stables.—When floor 
is of cement concrete with gutter 14 inches wide 
by G inches deep, and 4 feet 4 inches from gutter 
to wall, give 2.0; when gutter is of less dimen- 
sions, deduct 0.2 or more; when distance from 
gutter to wall is less than 4' 4", deduct 0.2 or 
more. For sound tight wooden floor and con- 
crete gutter, dimensions as above, allow 1.3; 
for cracks in floor deduct from this 0.5 or more. 
For iron stanchions and concrete manger give 
1.0; for stanchions of dressed lumber, painted, 
with concrete manger, give 0.9; for stanchions 
and mangers of dressed lumber, painted, give 
0.6; deduct 0.2 for lack of paint. For rough 
wood stanchions and mangers, allow not more 
than 0.3, according to condition. 
14. STABLES. Provision for Light.—Give as directed 
on card. Make no allowance for doors, unless 
they have glazed sash, nor for cracks. Actually 
measure the area of light openings. 
15. STABLES. Ventilation.—Give as directed on card. 
Actually measure dimensions of stables. Make 
no allowance for doors or cracks. For open-sided 
barns with at least three feet vertical of open 
space along both sides between top of side wall 
and eaves of roof, allow 1.0 for windows. 
16. UTENSILS. Construction and Condition of Uten- 
sils.—When all seams are well soldered, with 
no rough or rusty places, give 1.0; when seams 
are rusty or broken in spots, give 0.7 or less; 
for battered utensils, deduct 0.1 or more. A DAIRY SCORE CARD 
415 
17. UTENSILS. Water for Cleaning.—Water piped 
from clean sources to a sink, allow 1.0; water 
carried in buckets from clean source, allow 0.5; 
water in kitchen, allow 0.2; water from doubtful 
source, allow nothing. 
18. UTENSILS. Small Top Milking Pail.—Gurler, 
Sterilac or equal small top strainer pails for all 
milkers, and all milkers using them at all 
milkings, allow 5.0; Fishmouth or equal pails, 
ditto, allow 4.0; ordinary hooded pails, ditto, 
allow 2.0. Deduct in proportion for any 
milkers using open ordinary pails. 
19. UTENSILS. Milk Cooler.—Brine, or duplex 
water and brine, cooler, give 4.0. Perfection or 
equal tubular water cooler, give 2.5; conical 
water cooler, give 1.0; if iced to at least one-half 
inside water capacity, allow 1.5. Deduct for 
insufficient capacity of cooler, or if not used at 
every milking. 
20. UTENSILS. Clean Milking Suits.—Clean white 
suits and caps for milking only, allow 1.0; clean 
colored ditto, allow 0.6. Deduct if not kept in 
clean closet between milkings, or if soiled. 
Allow no credit under this item if no special 
milking suits. 
21. MILK ROOM OR MILK HOUSE. Location.— 
If corral is within 50 feet of milk house, deduct 
0.5; if milk house is more than 30 feet 
from milking barn, deduct 0.3. If milk room 
opens direct into milking barn without inter- 
vening room or vestibule and doors, deduct 
0.5. Deduct for dusty, dirty or insanitary 
surroundings. 416 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
22. MILK ROOM OR MILK HOUSE. Construction 
of Milk Room. Floor, Walls and Ceiling.— 
Floor, and walls to at least 4 feet in height, of 
smooth finish cement concrete, ceiling of smooth 
tongue and groove well painted with white or 
light colored paint, allow 1.0; plastered ceiling 
deduct 0.1; plastered walls deduct 0.1; ceiling 
not painted, deduct 0.1; walls not painted deduct 
0.2. Walls and ceiling of rough wood, floor 
smooth concrete, allow 0.4; floor of wood, allow 
not more than 0.2. Light, Ventilation and 
Screens.—For glass windows on opposite walls, 
hinged at bottom, with hinged screens, double 
self-closing screen doors with intervening vesti- 
bule, and screened opening in roof, allow 1.0. 
Deduct 0.5 or more for lack of screens, or for 
screens in poor or ineffective condition. Deduct 
0.3 or more for insufficient or poorly distributed 
light. 
23. MILK ROOM OR MILK HOUSE. Facilities 
for Steam.—For steam piped from steam boiler 
of ample capacity, give 2.0; steam from ordinary 
boiling apparatus, 1.0; for actually boiling water 
allow 0.5; for hot, but not actually and contin- 
uously boiling water, allow not more than 0.3. 
For hot water in kitchen allow nothing. 
III. METHODS. 
24. COWS. Clean.—When cows are curried and well 
brushed at least one-half hour before milking, 
and udders are kept well clipped, give 6.0; 
ditto, once a day, allow 5.0; if udders are not 
kept well clipped, deduct 1.0 to 2.0, according 
to length of hair on udders. If free from A DAIRY SCORE CARD 
417 
visible dirt, but not curried, brushed and clipped, 
allow up to 3.0; when soiled with mud or manure, 
or dusty, allow from 0.0 to 2.0 according to 
condition. 
25. STABLES. Cleanliness.—When floor is washed 
with hose twice daily after milking, give 2.0; 
if swept clean with broom, ditto, give 1.5; if 
scraped well with shovel, ditto, give 1.0; once 
daily, give one-half of above. If walls are 
spattered with dirt or manure, allow 0.2 to 0.0. 
Deduct 0.5 to 1.0 according to amount of dust 
and dirt on ceilings and ledges. When mangers 
and partitions are hosed clean twice daily, 
give 1.0; if swept ditto, allow 0.6; once daily, 
give one-half of above. If floors and mangers 
not swept, hosed or scraped at least once daily, 
allow nothing under their respective items. 
Windows dusty or dirty, allow 0.2 to 0.0; if no 
windows, allow 0.5 under that item. 
26. STABLES. Stable Air at Milking Time.—Freedom 
from Dust.—Where no hay or other dry feed is 
stored in milking barn, and no hay or dry feed 
is fed at milking time or for one hour previous, 
and no dustiness from corral or adjacent 
surroundings, give 2.0; deduct 1.0 for violation 
of above feeding rules; for dusty air from other 
causes deduct from 0.5 to 1.0. Freedom from 
Odors.—If no strong odor noticeable when 
entering milking barn, and no strong scented 
roots or feed are fed at milking time or for one 
hour previous, allow 1.0; deduct from 0.1 to 0.4 
for violation of above feeding rules; deduct an 
additional 0.2 to 0.6 according to intensity of 
odors. 418 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
27. STABLES. Barnyard. Clean—When scraped 
at least once a week, give 1.0. Deduct for dusti- 
ness, manure accumulations, etc., from 0.3 to 
1.0. Well Drained. If dry, smooth and hard 
surfaced, give 1.0; deduct 0.3 to 1.0 for uneven- 
ness, mud, pools of water, etc. 
28. MILK ROOM OR MILK HOUSE. Cleanliness 
of Milk Room.—When clean, airy and free from 
odors, give 3.0. When dried milk, sour milk, 
dust or dirt are found on walls, floor, utensils or 
equipment, deduct 1.0 to 2.0. When junk or 
unnecessary articles are stored in milk room, 
deduct 0.5 to 1.0. If presence of flies is notice- 
able, allow not more than 1.0 under this 
item; if flies are decidedly numerous, allow 
nothing. 
29. UTENSILS AND MILKING. Care and Clean- 
liness of Utensils. Thoroughly Washed.—Well 
washed and scrubbed with soap or compound 
in hot water promptly after each milking, give 
2.0; deduct 0.5 for unnecessary delay in washing 
(more than one hour after using). Deduct 
0.2 for cold water; deduct 0.5 for lack of soap or 
compound; deduct 0.3 for lack of brushes. 
30. UTENSILS AND MILKING. Care and Clean- 
liness of Utensils. Sterilized in Steam for 15 
Minutes.—Steam under pressure of at least 
10 lbs. per sq. inch for 15 minutes or more, 
give 3.0; for abundant streaming steam in 
steam chest with less than 5 lbs. but more than 
1 lb. pressure, for 15 minutes, give 2.0; deduct 
one-half of above for 10 minutes’ steaming; 
allow not more than 0.5 for less than 10 minutes 
steaming as above. Placed over Steam Jet. If A DAIRY SCORE CARD 
419 
placed over strong steam jets for 10 minutes 
or more, give 2.0; less than 10 minutes and more 
than 5 minutes, 0.5; less than 5 minutes, allow 
nothing. Deduct for insufficient steam supply. 
Scalded with Boiling Water. Utensils and 
bottles completely immersed in actually boiling 
water for 10 minutes or more, allow 1.0; for 5 
minutes or more, give 0.4; less than 5 minutes 
actual boiling, allow nothing. If hot or boiling 
water is poured into utensils, allow not more than 
0.2. If immersed in water not actually and 
continuously boiling, allow not more than 0.3. 
If utensils or bottles are rinsed, after steaming or 
boiling, in cold water, allow no credit under this 
item, and deduct 20.0 from final score. If 
utensils or bottles are rinsed, after steaming or 
boiling, in approved strength of B. K. or equal 
solution for at least 10 minutes, and then 
thoroughly drained, allow up to 2.5 for steam 
jet or boiling, but allow nothing additional if 
steam under pressure is used. Note use of 
solution, and strength, on back of score card. 
31. UTENSILS AND MILKING. Protected from 
Contamination.—If utensils and bottles are 
inverted in racks in well ventilated and screened 
room or compartment free from flies and dust, 
allow 3.0; if pins or projections extend into the 
interior of utensils or bottles while on racks, 
deduct 1.0; deduct 1.0 to 2.0 for presence of 
flies or dust; deduct 0.5 to 1.0 for outside expo- 
sure. If attendants in handling utensils or 
bottles after sterilizing, put hands or fingers 
inside of bottles or utensils, allow nothing 
under this item, and deduct 10 from final score. 420 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
32. UTENSILS AND MILKING. Cleanliness of 
Milking. Clean, Dry Hands.—When hands of 
milkers are thoroughly washed with soap and 
water, with paper or individual towels, imme- 
diately prior to beginning milking, and as often 
as hands are soiled during milking, give 4.0; 
if not, deduct 2.0 to 4.0, according to condition 
of hands. If any milker milks with wet hands, 
allow nothing under this item, and deduct 20 
from final score. If there is no wash stand with 
running water, soap and paper or individual 
cloth towels in milking barn or milk room, 
deduct 1.0 to 2.0. Udders Washed and Wiped. 
Udders and flanks well washed with hose and 
sponge, and udders dried with a clean cloth 
within one-half hour before milking, give 7.0; 
not dried, deduct 1.0; dried with dirty cloths, 
deduct 2.0 to 4.0, according to condition of 
cloth. Udders washed with clean cloth and 
clean water in bucket, using fresh water for each 
cow, and dried with clean cloth, allow 6.0; 
deduct as above for not drying and for dirty 
cloths. If wiped with clean wet cloths, allow 
4.0; deduct 1.0 to 3.0 according to condition of 
cloth and effectiveness of cleaning. For dry 
cloth or brush used at least 15 minutes before 
milking, allow" 1.0; deduct 0.3 to 0.8 according to 
ineffectiveness of cleaning. From all of the 
above a general deduction may be made for any 
ineffectiveness of cleaning. 
33. HANDLING THE MILK. Cleanliness of 
Attendants in Milk Room.—Deduct 0.2 to 1.0 
for dirty clothing. If hands are not well washed 
with soap and water, and dried with clean paper A DAIRY SCORE CARD 
421 
or individual cloth towels immediately before 
commencing work with the milk, deduct 0.2 
to 1.0. 
34. HANDLING THE MILK. Milk Removed 
Immediately from Stable without Pouring from 
Pail.—If milk is poured from pail in milking 
barn, allow nothing under this item. If milker 
waits to fill two pails before removing from 
barn, deduct 0.5. 
35. HANDLING THE MILK. Cooled Immediately 
After Milking Each Cow.—Milk put over cooler 
as soon as cow is milked, give 3.0; as soon as 
pail is filled, give 2.0; within 15 minutes after 
milk is drawn from cow, allow 1.0; worse than 
this, allow nothing. 
36. HANDLING THE MILK. Cooling.—The cool- 
ing must take place within one-half hour after 
milk is drawn from the cow, otherwise allow 
nothing under this item, but allow credit under 
storage. 
37. HANDLING THE MILK. Transportation.— 
Statement in parenthesis following this item on 
card to be followed only insofar as it meets the 
following requirements: if delivery twice a day 
is on ice between May 1 and October 1, and 
under thoroughly wet sacks between October 1 
and May 1, allow perfect score for storage and 
transportation. If worse delivery conditions, 
deduct according to temperature of milk at 
completion of afternoon delivery. 
38. EMPLOYEES. Medical Examinations must be 
made by licensed physicians, who must render a 
signed written statement that they have made a 
complete and careful physical examination of the 422 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
employe or proposed employe, and that, lie 
exhibits no visible evidence, lesions or symptoms 
of diphtheria, scarlet fever, open tuberculosis, 
dysentery, typhoid fever, syphilis, gonorrhoea 
or other communicable disease. Laboratory 
specimens may be taken by the examining 
physician, but for the sake of uniform technique 
it is preferred that specimens be taken by the 
county health officer. Full-time health officers 
shall make no charge for taking laboratory 
specimens. Nose and throat swabs, sputum, 
and feces and urine specimens are required as a 
routine; where venereal infection is suspected, 
blood for a Wassermann, or smears for gono- 
coccus, as the case may be, shall also be taken APPENDIX VII 
A CHART FOR TEACHERS 
Contagious Diseases of Children 
Disease 
Early symptoms j Site of eruption ! 
Character of eruption 
or symptoms 
Scarlet fever 
Sore throat, high 
fever, chills, vomit- 
ing, swelling of neck 
glands 
Face, abdomen and 
wrists; spreads 
rapidly 
Fine scarlet points, 
soon running to- 
gether to form a 
scarlet rash 
Diphtheria 
Sore throat, head- 
ache, tender at angle 
of jaw 
Throat and nose 
Dirty white mem- 
brane in throat; 
sometimes in nose 
Measles 
Running nose, in- 
flamed eyes, fever, 
cough 
Face, spreading down- 
ward over body 
Small, dark-pink spots 
tending to group 
themselves in cres- 
cents 
Chickenpox 
Slight fever, some- 
times headache 
Chest, back and body 
generally 
Successive crops of 
watery pimples that 
form scabs 
Mumps 
Fever, headache, dry 
skin, rapid pulse 
At angle of jaw, some- 
times under jaw 
Swelling, tenderness, 
painful swallowing 
Whooping cough... 
Cough, growing worse, 
hard and ringing 
Spasmodic cough fol- 
lowed by crow on 
taking breath, vomit- 
ing 
Smallpox 
Chills, fever, vomit- 
ing, intense head- 
ache and backache 
Face, neck, trunk, 
limbs, especially to- 
ward hands and feet 
Hard pimples, thin, 
pustular, with pit in 
center, thin scabs 
German measles.... 
Swelling of neck 
glands, and tender- 
ness, fever, sore 
throat 
Face and chest, 
spreading rapidly 
j Rose-colored spots on 
first day 
423 424 
A CHART FOR TEACHERS 
Symptoms Which Should Make One Suspicious of Commencing 
Contagious Disease 
1. Disisnlination to play or study 
2. Unuucal “tired feeling" 
3. Drowsiness 
4. Lack-lustre eyes 
5. Cheeks flushed or pallid 
0. Chills 
7. Vomiting 
8. Cough 
9. Sweating 
10. Eruption on skin 
11. Discharges from nose, throat or ears 
12. Swelling in neck 
13. Eyes red or inflamed 
14. Eyes discharging 
15. Sore throat 
1G. Fever APPENDIX VIII 
A. TECHNIQUE OF SCHICK TEST 
The following technique for performance of the Schick 
Test, to determine immunity to diphtheria, is taken entirely 
from Rosenau’s Preventive Medicine and Hygiene, Pages 
1497-1498, Fourth Edition, D. Appleton & Co., New York. 
“THE SCHICK TEST 
“Object.—To determine the presence or absence of diph- 
theria antitoxin in the blood of the subject under test. 
“A minute quantity of toxin (1/50 M.L.D.) is injected 
intracutaneously and a local reaction follows if there is less 
than 1/30 of a unit of antitoxin per c.c. of blood. The 
explanation of the test is that when antitoxin is present, the 
toxin is neutralized and no injury to the tissues occurs. A 
negative reaction therefore indicates the presence of 
antitoxin {immunity). A positive reaction indicates the 
absence of antitoxin {susceptibility). 
“Diphtheria toxin is diltued so that 0.1 c.c. equals 1/50 
of the M.L.D. for a 250-gram guinea-pig. This amount 
(0.1 c.c.) is injected with a 1 c.c. syringe and fine needle 
mfracutaneously on the flexor surface of the forearm or arm. 
A good guide for the insertion of the needle into the proper 
layer of the skin is to be able to see the oval opening of the 
needle through the superficial layers of the epidermis. A 
properly made injection is recognized by a distinct wheal- 
like elevation, which moves with the skin, and shows the 
prominent openings of the hair follicles. The results of the 
test should be read and noted daily. 
425 426 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
“The reaction that results at site of injection may be 
either positive, negative, pseudo, or combined positive and 
pseudo. 
“(1) Positive.—Trace of redness in 12 to 24 hours. 
Distinct in 24 to 48 hours. Reaches height on 3rd to 4th 
day. Leaves circumscribed scaling area of brownish pig- 
mentation which persists for 3 to 6 weeks. 
“(2) Negative. — No reaction at site of inoculation. 
“(3) Pseudo.—Local anaphylactic response of the tissue 
cells due to the protein substances which are present in the 
toxic broth used for the test. Reaction appears early— 
in from 6 to 18 hours—reaches its height in 36 to 48 hours, 
disappears on the 3rd or 4th day. There is generally no 
scaling. At its height, the pseudo reaction shows varying 
degrees of infiltration and appears as a small central area of 
dusky redness with a secondary areola, which gradually 
shades off into the surrounding skin. The reaction may 
also have a rather uniform appearance and be two to three 
times the size of a true reaction. Compare with control. 
“(4) Combined.—Positive and pseudo reaction in the 
same individual. The central area of redness is larger and 
better defined, the amount of infiltration is also more marked, 
a definite area of scaling brownish pigmentation is observed 
after the pseudo element has disappeared in the test. 
“Pseudo, combined and doubtful reactions, in the 
absence of suitable controls should be regarded as positive to 
be on the safe side. 
“Control.—With toxin heated to 80° C. for 30 min- 
utes, or with toxin neutralized with antitoxin, t,o~ help 
interpretation. ” 
B. DISINFECTION METHODS 
Much might be said on the details of disinfection, but 
a few brief rules will meet all practical requirements of a DISINFECTION METHODS 
427 
small health department. In fact, the whole subject is 
summed up in the statement by Rosenau that, “ Dryness, 
sunlight and cleanliness are the keynotes of sanitation in the 
modern acceptation of the term. ” Given these factors, no 
pathogenic organism can long retain its virulence and 
usually dies very quickly, with the exception of the few 
spore-formers. We may divide the methods of disinfection 
according to the materials or places to be treated. 
1. Eating utensils, clothing, washable bedding. 
(a) Boil for 10 minutes, or expose to steam under 
pressure of 15 pounds for 5 minutes. 
(b) Some of these things can be baked in a hot oven for 
20 minutes without injury. 
(c) Soaking for 2 hours in a 5 per cent, solution of 
formaldehyd or bleaching powder is also effective. 
2. Bedding and clothing that cannot be boiled. Expose to 
the direct rays of the sun for 8 hours, turning them occa- 
sionally so that all parts are reached by the sun. This 
applies to mattresses, pillows, blankets, quilts, woolen and 
silk clothing, especially. It may also be applied to toys 
and books that are not to be destroyed. 
3. Floors, walls, furniture. Scrubbing thoroughly with 
soap and hot water, followed by airing for a day or two, is 
all that is needed. It is only necessary to wash the walls to a 
point as high as that reached by particles of sputum that 
may have been sprayed out by the patient in coughing or 
sneezing. 
4. The patient should have a hot bath and shampoo and 
should put on clean clothing, before leaving his room. 
5. The nurse should make a change of clothing at the 
same time. 
6. Discharges and secretions from the patient. 
(a) Whenever possible, these should be burned very 
promptly. 428 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
(6) Soaking for three or four hours in a 5 per cent, 
formaldehyd solution or a fresh solution of 
bleaching powder will be effective, provided the 
mixture is frequently stirred in order to secure 
complete penetration. This is especially impor- 
tant with feces and sputum. 
The above suggestions will usually be all that is required 
for either concurrent or terminal disinfection, in a case of 
communicable disease in a home or institution, provided 
they are thoroughly applied. 
It will be noted that nothing is said of fumigation. The 
reasons for this have been given elsewhere. If it happens 
that the disease is one carried by insects, it will then be 
necessary to fumigate in order to destroy those that remain 
about the sickroom. The best and most easily applied 
insecticide is sulphur dioxid gas, generated by burning dry 
sulphur. Following is the method usually employed. 
(а) Remove all movable articles from the room, after 
disinfection. 
(б) Metals and paint may be coated over with vaseline 
to prevent corrosion or tarnishing. 
(c) Measure out 3 or 4 pounds of powdered sulphur 
for each 1000 cubic feet of space. 
(d) Provide sufficient metal pots or trays so that there 
will be no more than 30 pounds of sulphur to 
each. Put the sulphur in these containers, 
heaping it up in a cone-shaped pile, and set each 
container in a large tub or pan of water. Do not 
allow the bottom of the container to rest on the 
bottom of the vessel holding the water. 
(e) Seal all cracks and crevices in the room. 
(/) Drop a small piece of rag or cotton, soaked in 
kerosene, or alcohol, on top of each pile of 
sulphur. When all are ready, ignite each one, 
starting with those farthest from the door. DELOUSING METHODS 
429 
(;g) When all are burning, close the door and place 
wet cloths over the cracks, or hang a wet sheet 
over the entire door frame. 
(h) Keep watch for fire originating from the burning 
sulphur. 
(i) Leave room closed for at least 8 hours. 
C. DELOUSING METHODS 
The following technique for delousing under varying 
conditions is extracted from Rosenau’s Preventive Medicine 
and Hygiene, Pages 366-369, Fourth Edition, D. Appleton 
& Co., New York. 
“Delousing.—The best delousing methods should not 
only destroy lice and their eggs, but also the viruses trans- 
mitted by the insect. Fortunately, the viruses of relapsing 
fever, typhus fever and trench fever are comparatively frail; 
they are destroyed at 70°C. moist heat for 30 minutes. 
Lice and nits are killed at this temperature; also at 55°C. 
dry heat in 5 minutes. It is a comparatively simple matter 
to kill lice and their nits—only the administrative aspect 
of the problem presents any real difficulty. The most 
frequently used methods are heat, chemicals or storage. 
11 Heat.—Dry heat is convenient, but not effective in 
large scale operations because it lacks the power of penetra- 
tion. Dry heat has the advantage in the case of leather 
material and rubber goods, which may be thus disinfested 
without injury. Shoes are rarely infested; in fact, leather 
and rubber articles as a rule need not be treated except 
in the presence of heavy infestations or an epidemic. 
Steam penetrates better, is quicker, surer; and it also 
disinfects. 
“Heat may be applied in a great variety of ways: boiling 
water, Serbian barrel, steam, flat iron, hot oven, hot air 
boxes or huts, steam disinfectors. 430 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
“The flat iron was employed in some armies. The 
method is effective, but impracticable on a large scale as it 
is time-consuming. If used in connection with a delousing 
plant, the number of ironers would have to equal the 
number of bathers so that the clothes would be ready for the 
men when they came out of the bath. It takes about 15 
minutes to iron a uniform and underclothes. 
‘ ‘ Hot ovens have been used. This method may be applied 
on a small scale. Care must be observed not to scorch the 
clothing. A very effective hot air method is the hot air 
hut, described by Captain Orr of the Canadian Army. The 
penetration with dry heat is not as complete as when using 
steam. Stagnant hot air is less effective than circulating 
hot air. In the front area, in dugouts and trenches, the 
hot box may be used. This box is based on the principle 
of the fireless cooker, and used by heating a piece of metal, 
and placing the clothing, which is protected from coming 
in contact with the metal, over it. The temperature 
obtained is sufficient to destroy lice and eggs. 
“Hot water—Lice and eggs immersed in water at 70°C. 
for 30 minutes are killed with certainty—this method is not 
practical on a large scale. 
“Steam Disinfectors.—The large commercial steam dis- 
infectors are the best and quickest way of delousing large 
quantities of clothing. With the aid of the vacuum, pene- 
tration is sure and the materials are both disinfested and 
disinfected. Steam may also be used in improvised 
methods in a freight car, obtaining the steam from the 
locomotive; or in the compartments of a ship. 
“The steam laundry is a good delousing apparatus, 
provided live steam is run into the wash wheel. It takes 
about 15 minutes to insure a proper temperature. DELOUSTNG METHODS 
431 
“Clothing can be freed of lice by storage. Sufficient 
length of time must elapse for the adult lice to die and 
nits to hatch. Nuttall advises clothing stored in a dry 
temperature for two to three weeks. Since hatching has 
been delayed thirty-five days by low temperature, it would 
be safe to allow thirty to forty days during cool weather. 
“Chemicals are used for two purposes; to destroy lice and 
nits on clothing and hair, or to repel them. Numerous 
licicides have been recommended, but experience has shown 
most of them to be worthless; they may destroy lice, but 
rarely do they destroy nits. 
“The most effective insecticides for louse control are 
kerosene, naphthalene, carbon bisulphid and lysol. The 
English employed the N.C.I. powder with some success. 
This consists of 
Naphthalene 96 per cent. 
Creosote 2 per cent. 
Iodoform 2 per cent. 
“The commercial naphthalene is the best. This powder 
acts as a repellent; therefore it should be dusted into the 
clothing frequently—every three days. The best results 
are obtained by dusting the seams of the clothing freely 
and then rolling in a blanket. Care must be exercised in 
using the powder in the fork of the trousers, as it may cause 
smarting. Some observers have had just as good results 
with crude naphthalene. A powder consisting of talc, 20 
gms., creosote, 1 c.c., sulphur, 0.5 gms., has been suggested 
by Moore, and is supposed to be effective. It causes less 
irritation to the skin than the N.C.I. powder. 
“In conjunction with the N.C.I. powder, the English 
use a mixture known as Vermijelli, which consists of: 
Crude mineral oil pints 
Soft soap 3 lbs. 
Water About pint 432 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
“This is smeared in the interior seams of the clothing. 
Impregnation of underclothing with various chemicals has 
given unsatisfactory results. Sachets are only effective 
for a short time. 
“Various fumigation methods have been recommended, 
but experience has shown that most of the gases do not 
destroy nits. The value of sulphur and formaldehyd has 
been overestimated. Nits are not destroyed. The use of 
hydrocyanic acid gas has been recommended, and it was 
found that 3 ounces to ounces per 100 cubic feet would 
be sufficient to kill adult lice and to prevent eggs from 
hatching, when the surface of the clothes are freely exposed 
to the fumes for one-half hour/7 APPENDIX IX 
FORMS 
The following forms are offered as suggestions. They 
have been in actual use in small health departments and 
have given satisfaction. None of them should be followed 
blindly, but each item should be most carefully studied in 
relation to the peculiarities of local conditions. Following 
through a series of cases, in imagination, the health officer 
can frequently discover where he may wish to make changes, 
before he has gone to the expense of printing rather costly 
forms. This may make quite a difference in a small budget. 
See Part I, Chapter IV. 
FORM I 
Communicable Disease Card—Face 
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 
PALO ALTO HEALTH DEPARTMENT (^e X° 
Record of Communicable Disease gex 
Disease Color 
Name 
Residence • Phone 
School or Occupation 
Date Reported Physician 
Quarantine Isolation Placard 
Date First Symptoms Date Exanthem 
Last Day Attended School or Business 
Laboratory Examinations 
Is Nurse Isolated with Case Removed to Hospital 
Previous Attack Vaccination 
Milk Supply 
Library Books Laundry 
School Notice State Notice 
Died—Released School Permit Disinfected 
(over) 
433 434 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Note dates at top. A small metal signal can be slipped over 
the date on which the next action is required in the case 
and the cards filed alphabetically or numerically. 
Communicable Disease Card—Reverse 
Name 
Age 
School or Occupation 
Address 
Persons Exposed to Patient 
Other Data: 
Inspector. FORMS 
435 
FORM II 
Laboratory Record Card 
To be sent to laboratory with the specimen. 
CITY OF PALO ALTO 
CLINICAL LABORATORY No 
PALO ALTO HOSPITAL 
Date 19 
Physician Address 
Patient Address 
Specimen 
To be examined for 
Diagnosis 
Remarks 
Charges ■ Reported 
By phone, mail, in person. 
Bacteriologist. 436 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
FORM III 
Notice to Exclude from School 
This form was printed in red to attract attention. 
CONTAGIOUS DISEASE-WARNING 
PALO ALTO BOARD OF PUBLIC SAFETY 
HEALTH DEPARTMENT 
Palo Alto Public Schools: 
You are instructed to exclude from school 
until further notice. 
has been exposed to 
has contracted 
Please notify the teacher. 
Respectfully, 
Health Officer. 
FORM IV 
Permit to Return to School 
CONTAGIOUS DISEASE-PERMIT 
PALO ALTO BOARD OF PUBLIC SAFETY 
HEALTH DEPARTMENT 
Palo Alto Public Schools: 
Kindly Permit 
to attend school. 
Respectfully, 
Health Officer. FORMS 
437 
FORM V 
Mailed each week to the press, to physicians and others 
interested. 
Weekly Report of Morbidity 
HEALTH DEPARTMENT 
WEEKLY MORBIDITY REPORT 
PALO ALTO CALIFORNIA 
For the week ending Saturday. 
Disease 
Cases 
under 
isolation 
Cases 
reported 
during 
week 
Cases 
released 
during 
week 
Cases 
under 
isolation 
Anthrax -. 
Cerebrospinal meningitis 
Chickenpox 
Diphtheria 
Erysipelas 
German measles 
Gonococcus infection 
Influenza 
Leprosy 
Malaria 
Measles 
Mumps 
Plague 
Pneumonia 
Poliomyelitis 
Rabies 
Scarlet fever 
Smallpox 
Syphilis 
Tetanus 
Tuberculosis 
Typhoid fever 
Typhus fever 
Whooping cough 
Other 
Births reported 
Deaths reported 
Health Officer 438 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
FORM VI 
Daily Record or Diary 
This might be printed on a sheet X and the 
remainder of the space used for a narrative report or notes. 
If a weekly or monthly report is to be made to the state 
health department, or other agency, this form should be 
checked against the one used for such reports, before being 
adopted. 
Name 
DAILY RECORD 
Date 
Inspections: 
Dairy 
Number 
Ti 
ne 
Disease 
Food supplies 
Sanitary 
School 
Laboratory: 
Diagnosis 
Food 
Milk 
Water 
Office: 
Correspondence 
Records 
Reports 
Conferences 
Examinations 
Home visits 
Vaccinations 
Mileage 
Totals 
Health Department, Palo Alto, Calif. FORMS 
439 
FORM VII 
Combined Complaint and Inspection Record and Notice to 
Abate Nuisance 
Original on white paper, duplicate on yellow, and 
bound in pads. Punched for ring binder. Size of sheets 
8y2" X 11". 
DEPARTMENT OF HEALTH No 
CITY OF SAN JOSE Date 192.... 
CALIFORNIA Hour A. M., P. M. 
INSPECTION AND COMPLAINT RECORD 
COMPLAINT— Complainant Defendant 
Verbal Address Address 
Phone Telephone Telephone 
Letter 
Nature of Complaint 
Received by Referred to 
INSPECTION NOTES:—Location of Premises 
Premises owned by 
Premises occupied by 
Date Inspected 192 A. M., P. M., Inspected by 
Notice to abate given 192.. in person, mail, phone. 
NOTICE TO ABATE 
You 
owner 
agent 
occupant 
of the above described premises, are hereby directed to abate the above described nuisances 
or violations of law prior to , 192.... in the following manner: 
Failure to abate the above nuisances or violations of law is a misdemeanor, punishable by 
fine or imprisonment. This is the notice. 
Health Officer 
by 
I hereby acknowledge receipt of the above 
notice, this day of 
192 
(Signature) 
Reinspection 192 
Reinspection 192 
Reinspection 192 
Final Inspection 192 
Date of Abatement 192 440 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Continuous Record of Physical Examination of School Child 
This record is sent with child’s other papers to each new grade or school entered. Size 
of sheet X 11". 
PALO ALTO HEALTH DEPARTMENT 
[RECORD OF PHYSICAL EXAMINATION 
Name Date of birth 
Surname Given name 
Residence Father 
(date) Name Nationality 
Residence Mother •.•••:. 
(date) Name Nationality 
Residence 
(date) 
Residence 
('Hate') 
Date 
School 
Grade 
K 
1 
2 
3 
4 
5 
6 
7 
8 
1 Age 
2 Weight 
3 Height 
4 Vision 
5 Hearing 
6 Tonsils 
7 Adenoids 
8 Glands 
9 Teeth 
10 Nerves 
11 Nutrition 
12 Skin 
— 
— 
FORM VIII FORMS 
441 
Chickenpox 
Communicable Diseases (note date of each) 
Pneumonia 
Remarks 
Diphtheria 
Scarlet fever 
German measles Smallpox 
Influenza 
Typhoid fever 
Measles 
Whooping cough 
Mumps 
Examiner 442 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
FORM IX 
Report to Dairyman on Results of Milk Examinations 
Board of Public Safety 
Palo Alto, Cal. 
Health Department 
Samples from 
Month 
Day 
Milk 
or 
cream 
Bacteria per 
cc. 
Milk 
fat 
Solids 
not 
fat 
Remarks 
CITY ORDINANCE REQUIRES: 
Guaranteed Milk Bacteria per cc., 20,000, or less; Fat 3.8 per cent 
Guaranteed Cream. . . Fat 25.0 per cent 
Grade A cream Fat 18.0 per cent 
Grade A Raw Milk... Bacteria per cc., 100,000, or less; Fat 3.4 percent 
Grade A Pasteurized. Bacteria per cc., 10,000, or less; Fat 3.4 per cent 
Health Officer FORMS 
443 
FORM X 
Dairy Cow Record—Face 
PALO ALTO HEALTH DEPARTMENT 
TUBERCULIN TEST RECORD 
Owner ' 
Tag No Temporary No 
Breed Color 
Date 
Kind 
of 
test 
Veterina- 
rian 
Tuberculin 
amount, 
etc. 
Time 
injected 
Temperatures before and after, 
description of swelling, etc. 
Result 444 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
Dairy Cow Record—Reverse 
Diagram of cow is used for indicating identifying marks 
or areas of color. 
Owner 
Tag No * Temporary No 
Breed Height 
Color Brands 
Remarks FORMS 
445 
Regis. District 
Period 
Total 
Cause of death 
All causes 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
Typhoid fever (1) 
Smallpox (6) 
Measles (7) 
Scarlet fever (.8) 
Whooping cough (9) 
Diphtheria (10) 
Influenza (11) 
Other epidemic diseases (2-5, 21-30, 41-42) 
Tuberculosis of lungs (31) 
Tuberculosis other organs (32-37) 
Venereal infections (38—40) 
Cancer (43-49) 
Other general diseases (50-69) 
Meningitis (71) 
Other diseases nervous system (70, 72-86) 
Diseases of the circulatory system (87-96) 
Pneumonia (100-101) 
Other diseases of respiratory system (97—99, 102—107) 
Diarrhea and enteritis under 2 years of age (113) 
Other diseases digestive system (108-112, 114-127) 
Diseases genito-urinary system (128-142) 
Childbirth (143-150) 
Diseases early infancy (159-163) 
Suicide (165-174) 
Other violence (175-203) 
All other causes (151-158, 164, 204-205) 
— 
— 
— 
1 
For tabulating causes of death, by months, using the short list of causes. 
State of New Mexico, Bureau of Public Health 
FORM XI APPENDIX X 
BIBLIOGRAPHY 
Quite in keeping with the growth of sanitary science, the 
last few years have seen an increasing stream of literature 
upon all subjects touching this broad field. To give any- 
thing approaching a complete bibliography would only 
serve to confuse the student who is gaining his first impres- 
sions through the medium of books. On the other hand, it 
has been difficult to make a selection among the various 
excellent works that are offered. Probably no two bibliog- 
raphers would agree upon recommendations, but the 
authors offer here a list that they believe will meet all 
requirements of the average health officer. Indeed, a 
thorough assimilation of even a few of these books will 
furnish a solid foundation of knowledge in the science and 
art of sanitary practice and will open up new vistas that 
the student can follow more carefully as his tastes dictate. 
Valuable suggestions and helpful literature can be secured 
from the following sources: 
American Child Health Association, 370 7th Avenue, New York City. 
American Public Health Association, 370 7th Avenue, New York City. 
American Social Hygiene Association, 370 7th Avenue, New York City. 
American Society for the Control of Cancer, 25 W. 45th St., New York City. 
National Committee for the Prevention of Blindness, 130 E. 22d St., New 
York City. 
National Health Council, 370 7th Avenue, New York City. 
National Tuberculosis Association, 370 7th Ave., New York City. 
National Headquarters, American Red Cross, Washington, D. C. 
U. S. Public Health Service, Washington, D. C. 
The following books and pamphlets can be secured 
through the American Public Health Association, or direct 
from the publisher or book seller. Those marked with an 
asterisk (*) will be especially helpful to the beginner. 
446 BIBLIOGRAPHY 
447 
GENERAL PREVENTIVE MEDICINE AND HYGIENE 
Boyd, Preventive Medicine. 
Chapin, How to Avoid Infection. 
* Chapin, The Sources and Modes of Infection. 
Darlington, Health and Efficiency. 
Fitzgerald, An Outline of the Practice of Preventive Medicine. 
Jenkins, Health and Disease. 
Nichols, Carriers in Infectious Diseases. 
* Park, Public Health and Hygiene. 
* Rosenau, Preventive Medicine and Hygiene. 
* Simon, Human Infection Carriers. 
Simon, Infection and Immunity. 
Vaughan, Epidemiology and Public Health. 
ADMINISTRATION, PUBLICITY AND SOCIAL MEDICINE 
* Brend, Health and the State. 
Byrd, Forty Notifiable Diseases. 
Davis & Warner, Dispensaries: Their Management and Development. 
* Horwood, Public Health Surveys. 
* MacNutt, A Manual for Health Officers. 
Morgan, Public Relief of Sickness. 
National Health Council, List of Health Films. 
Red Cross, Handbook of Social Resources. 
Richmond, What is Social Case Work? 
Routzahn, Traveling Publicity Campaigns. 
* Routzahn & Routzahn, The A-B-C of Exhibit Planning. 
Whipple, State Sanitation. 
LABORATORY 
d’Herelle, The Bacteriophage. 
Kolmer, Infection, Immunity, Specific Therapy. 
Rivas, Parasitology. 
A.P.H.A., Standard Methods for Examination of Water. 
A.P.H.A., Standard Methods for Examination of Milk. 
* Stitt, Practical Bacteriology. 
MATERNAL, CHILD AND SCHOOL HYGIENE 
* Baldwin, Physical Growth of Children from Birth to Maturity. 
Eve, Manual for Health Visitors and Infant Welfare Workers. 
* Holt, The Care and Feeding of Children. 
MacCarthy, The Healthy Child from Two to Seven. 
Milnes, Child Welfare. 
Van Blarcom, Obstetrical Nursing. 448 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
FOOD AND NUTRITION 
Chittenden, The Nutrition of Man. 
Kilbourne, The Pasteurization of Milk. 
* Lusk, Elements of the Science of Nutrition. 
* McCollum, The Newer Knowledge of Nutrition. 
* North, Farmers’ Clean Milk Book. 
Rosenau, The Milk Question. 
SANITARY ENGINEERING AND SANITATION 
* Howard, The House Fly. 
Kinnicutt, Winslow & Pratt, Sewage Disposal. 
Metcalf & Eddy, American Sewerage Practice (3 vols.). 
* Metcalf & Eddy, Sewerage and Sewage Disposal. 
Ogden, Rural Hygiene. 
Pierce, Sanitary Entomology. 
Whipple, The Microscopy of Drinking Water. 
INDUSTRIAL MEDICINE AND HYGIENE 
* Clark, Health Service in Industry. 
Dawson, Frankel & Dublin, Workingmen’s Insurance in Europe. 
Fed. Am. Engineering Societies, Waste in Industry. 
Goldmark, Fatigue and Efficiency. 
* Kober & Hanson, Diseases of Occupation and Vocational Hygiene. 
Tead & Metcalf, Personnel Administration. 
VITAL STATISTICS AND BIOMETRY 
Chapin, Field Work and Social Research. 
Davenport, Statistical Methods With Special Reference to Biological 
Variation. 
* King, Elements of Statistical Method. 
Newsholme, Elements of Vital Statistics. 
Population and Its Distribution. 
* Pearl, The Biology of Death. 
* Whipple, Vital Statistics. 
Yule, Introduction to the Theory of Statistics. 
MENTAL HYGIENE AND PSYCHOLOGY 
* Cotton, The Defective, Delinquent and Insane. 
Dewey, Human Nature and Conduct. 
Drever, Psychology of Everyday Life. 
Franz, A Handbook of Mental Examination Methods. 
* White, The Mental Hygiene of Childhood. 
* White, Principles of Mental Hygiene. BIBLIOGRAPHY 
449 
SOCIAL HYGIENE AND EUGENICS 
Clarkson, The Venereal Clinic. 
* Exner, The Rational Sex Life for Men. 
* Funk, Vice and Health. 
* Galloway, Biology of Sex for Parents and Teachers. 
* Galloway, The Sex Factor in Human Life. 
* Kneeland, Commercialized Prostitution in New York City. 
Popenoe & Johnson, Applied Eugenics. 
Stokes, The Third Great Plague. 
* Stokes, Today’s World Problem in Disease Prevention. 
Woolston, Prostitution in the United States. 
TUBERCULOSIS 
Calmette, Tuberculosis. 
Walters, Domiciliary Treatment of Tuberculosis. 
Jacobs, The Tuberculosis Worker. 
Krause, Environment and Resistance in Tuberculosis. 
OTHER DISEASES 
Dock & Bass, Hookworm Disease. 
Hoffman, Mortality from Cancer throughout the World. 
Ker, Infectious Diseases. 
* Stitt, Diagnosis and Treatment of Tropical Diseases. 
Turner, Ringworm among School Children and Its Treatment. 
Vaughan, Influenza: An Epidemiological Study. 
NURSING 
Brainard, The Evolution of Public Health Nursing. 
Brainard, The Organization of Public Health Nursing. 
* Gardner, Public Health Nursing. 
Porter, Applied Psychology for Nurses. 
Price, Hygiene and Sanitation for Nurses. 
Van Blarcom, Obstetrical Nursing. 
PERSONAL HYGIENE 
* Fisher & Fisk, How to Live. 
Rucker, Ten Talks to Girls on Health. 
HEALTH EDUCATION FOR CHILDREN 
Andress, The Teaching of Hygiene in the Grades. 
Andress & Andress, The Story of Rosy Cheeks and Strong Heart. 
* Griffith, Cho-Cho and the Health Fairy. 
O’Shea & Kellogg, Building Health Habits. 450 
ELEMENTS OF PUBLIC HEALTH ADMINISTRATION 
* Peterson, The Child Health Alphabet. 
* Ritchie, Primer of Hygiene. 
(The above list is taken largely from “Books for Sanitarians” issued by 
the American Public Health Association.) 
PERIODICALS DEALING WITH PUBLIC HEALTH 
American Journal of Public Health, American Public Health Ass’n, 
370 7th Avenue, New York City. 
The Public Health Nurse, National Organization for Public Health 
Nursing, 370 7th Avenue, New York City. 
The Nation’s Health, Hospital Publishing Co., Chicago, 111. 
Hygeia, American Medical Association, 535 N. Dearborn St., Chicago, 111* INDEX 
Aht, 173 
Accounts, classification of, 39 
checking, 40 
Achorion schonleinii, 220 
Agramonte, 359 
Agricultural agent, cooperation 
with, 26 
Air-borne infection, 182, 185 
Alcoholism as health problem, 165 
Algae, 105 
American Child Health Associa- 
tion, 69 
Ankylostoma duodenale, 225 
Anthrax, 193 
see headings in text 
Appropriations, budgets, 20 
estimates for, 20 
getting support for, 24 
B. coli, in water, 100 
B. typhosus, in water, 100 
Bacon, 157 
Balanitis gangrenosa, 337 
see headings in text 
Beeton, 60, 61, 87 
von Behring, 207 
Bell, 87 
Beriberi, 196 
see headings in text 
Bibliography, 446 
Biologicals, control of by U. S., 155 
Birth rates, calculation, 49, 51 
records, routine handling, 32 
registration, by Census Bureau, 
153 
Births, registration of, 41 
purpose of, 41 
statistics of, uses, 51 
unreported, checking of, 45 
Boards of health, state, functions 
of, 157 
Books for sanitarians, 446 
Brend, 63, 85 
Brill, 332, 333 
Brill’s disease, 333 
Bruce, 246 
Budd, 326 
Budgets, 20 
form of, 21 
getting support for, 24 
lump sum, 23 
relative values in, 22 
segregated, 23 
Bureau of Social Hygiene, N. Y., 347 
Byle, 301 
California State Board of Health, 92 
Carriers of infection, 182 
Carroll, 359 
Causes of death, in older children, 
91 
under one year, 77 
Certification, death, making of, 43 
Cesspools, danger of, 108 
Chancre, hard, 341 
soft, 338 
Chancroid, 338 
see headings in text 
Chapin, 126, 341 
Chickenpox, 198 
see headings in text 
Child hygiene, 89 
Bureau of Education in, 153 
causes of death, 89 
Children’s Bureau in, 153 
in general program, 369 
opportunity to reduce death 
rate, 12 
451 452 
INDEX 
Child hygiene, tendency of social 
worker in, 168 
under state, 159, 162 
under U. S. P. H. S., 155 
welfare, see Infant hygiene, 
Child hygiene, School hy- 
giene, prenatal care 
Chlorination of water, 101 
Cholera, 199 
see headings in text 
hog, effect of, 141 
Chronic diseases, reduction of, 
171 
Clinics, life extension, 14 
organization of, 393 
place of tuberculosis, 14 
of venereal disease, 14 
Combined city and county health 
department, 19 
Communicable diseases, chart of, 
for teachers, 423 
closing schools for, 93 
epidemiological card, 433 
form of notice to schools, 436 
of permit to re-enter, 436 
of report, 433 
general control of, 366 
infant mortality and, 78 
legal control of, 149 
notification forms, 32, 436 
nursing duties in, 379 
Conjunctivitis, acute contagious, 
203 
see headings in text 
Contact infection, control of, 189 
importance of, 184 
Control of communicable diseases, 
community measures, 
188 
in household, 188 
in patient, 186 
outline of methods, 189 
methods of, see under name of 
disease 
Cooperation, 372 
with agricultural agent, 26 
with fire department, 25 
with police, 25 
with schools, 25 
County health work, plan of, 365 
Courts, cooperation with, 26 
Cuban itch, 294 , - 
Curtis, 92 
Cystercercus bovis, 303 
cellulosae, 303 
Dairies, form of cow record, 443 
of laboratory report, 442 
records of, 35 
scoring, 35, 133, 408 
Dairy score card, 133, 408 
Davaine, 193 
Death certificates, 43 
routine handling, 33 
uses of, 41 
rates, by age groups, 54, 76 
calculation, 49, 52, 53 
of infants, 76 
nationality, effect of, 62, 164 
race, effect of, 62 
records, corrections, handling 
of, 32 
tabulation by causes, 33 
registration, by Census Bureau, 
153 
methods of, 42 
reasons for, 41 
statistics, uses of, 52 
Deaths, causes of, 77, 89, 91 
unreported, checking of, 44 
Defects of children, 95, 97 
correction of, 96 
Delousing, methods of, 429 
Dengue, 205 
see headings in text 
Dental hygiene, in schools, 96, 382 
Diagnosis, see under name of disease 
Diarrhea and enteritis, 77 INDEX 
453 
Diary for health officers, 36, 438 
Diphtheria, 207 
see headings in text 
infant mortality from, 79 
in schools, 95 
milk-borne, 131 
Dipylidimn caninum, 303 
Disinfection, 187 
concurrent, 190 
methods of, 426 
terminal, 190 
Dermacenter reticulatus, 282 
Droplet infection, 192 
Dysentery, 217 
see headings in text 
Eberth, 320 
Economic condition, relation to 
health, 164, 176 
Education, health, 142, 394 
by local health department, 365 
maternal and infant hygiene, 71 
under state, 159 
under U. S. P. H. S., 156 
Engineer, sanitary, in disease con- 
trol, 189 
future problems for, 173 
Engineering, sanitary, under state, 
161 
Entamoeba hystolytica, 218 
Environment, relation to health and 
welfare, 166 
Epidemics, state control of, 160 
Epidemiology, definition of, 181 
investigations in, 10 
Equipment, office, 37 
Estimates, methods of preparing, 
20 
of expense, 21 
planning, 22 
presenting, 22, 23 
Examination, school children, 383 
Exclusion from school, 10 
Excreta disposal, plan of, 367 
Favus, 220 
see headings in text 
Federal health agencies, aims of, 153 
Filaria bancrofti, 222 
Filariasis, 222 
see headings in text 
Finance, references on, 20 
Financing of health department, 20 
budgets, 20 
Flexner, 273 
Flies, control of, 121 
Fomites, 185 
Food handling, sanitation of, 140 
inspection, by Dept, of Agricul- 
ture, 153 
supervision of, 138, 159, 161 
supplies, future problems of, 173 
Foods, 137 
sanitary inspection of, 139 
sanitation of, 371 
U. S. control of, 138 
Forms, 433 
communicable diseases, notice 
to schools, 436 
record of case, 32, 433 
cow record, 443 
dairy records, 35 
epidemiological card, 433 
health officer’s daily record, 438 
laboratory record, 435 
reports, 36, 442 
mortality tabulation, 445 
nuisances, 34, 439 
office records, 31 
permit to re-enter school, 436 
report to dairyman, 442 
sanitary inspection, 439 
school child examination, 440 
weekly morbidity, 437 
Franz, 343 
Freeman, 273 
Frost, 273 
Fumigation, 190 
for insects, 428 454 
INDEX 
Functions, of local health depart- 
ment, 9 
of national health agencies, 153 
of state health department, 153 
Future of public health, 169 
Gaffky, 320 
Gambusia, 124 
Garbage, 185 
disposal of, 119 
Garget in cows, 292 
Genealogical Record Office, 60 
German measles, 223 
see headings in text 
Goldbergey, 261, 262 
Gonorrhea, 339 
see headings in text 
Gorgas, 239, 349 
Habeas Corpus, 149 
Health insurance, 176 
officer, limitations of power, 149 
non-medical, 16 
personal liability, 150 
physician as, 2, 16 
qualifications, 15 
qualities for, 5, 6, 28, 29 
relation to community, 2, 4, 
25, 26, 27 
sources of power, 148 
IIemameba falciparum, 240 
malariae, 240 
vivax, 240 
Heredity, immunity and, 62 
longevity and, 60 
public health and, 60 
scarlet fever and, 63 
tuberculosis and, 64 
typhus and, 63 
Hoffman, 165, 235, 236, 245 
Hog pens, 117 
Hookworm, 185, 225 
see headings in text 
Housing, 126 
Hydatid cyst, 303 
Hymenolepsis nana, 303 
Immigrant inspection by U. S., 155 
Immunity, heredity, effects of, 62 
see under name of disease 
Impetigo, 228 
see headings in text 
Incubation period, see under name 
of disease 
Indians, Navajo, tuberculosis in, 165 
Infancy, early, diseases of, 80 
mortality from, 80 
Infant hygiene, 75 
nursing duties in, 380 
reduction of death rate, 12 
under state, 159, 162 
Infant mortality, by age groups, 76 
causes of, 77 
English cities, 86 
rural, 86 
French urban and rural, 86 
heredity, effect of, 60, 87, 164 
longevity of parents and, 87 
milk supply and, 73 
nationality and, 85 
poverty in relation to, 61, 
88, 164 
prevention of, 77, 80 
public health nurse and, 81 
race, effect of, 84, 85, 165 
rates, calculation of, 55, 82 
errors in, reasons for, 82 
in cities, compared, 83, 86 
reduction of, in New York, 82 
sanitation and, 74 
volunteer agencies and, 74 
Infantile paralysis, 272 
Infection, modes of, 183 
see under name of disease 
Infective agent, see under name of 
disease 
Influenza, 230 
see headings in text INDEX 
455 
Insects, relation to disease trans- 
mission, 183, 184 
Inspectors, qualifications of, 17 
Interstate control, 148 
quarantine, 154, 155 
water supplies, in traffic, 155 
Isolation, definition of, 190 
routine, 11 
Itch, 283 
Jefferson, 294 
Jenner, 294 
Kitasato, 263 
Koch, 193, 200, 201, 207, 311, 320 
Laboratory, local, 161 
record forms, 435 
report forms, 36, 442 
state, 159, 161 
technician, qualifications, 17 
Lamblia intestinalis, 218 
Laveran, 240 
Lavinder, 273 
Law, public health, 147 
in states, 156 
Laws, state health, nature of, 148 
sources of, 148 
Lazear, 359 
Leake, 275 
Leprosy, 234 
see headings in text 
Leptospira ideroides, 360 
Levy, 74, 78 
Lice, 259, 333 
Local health department, 8 
functions of, 9 
personnel of, 14 
publicity by, 13 
reasons for, 8 
school hygiene by, 95 
officers, supervision by state, 
159 
Lockjaw, 304 
Loeffler, 207 
Longevity, hereditary aspects of, 60 
relation to infant mortality, 164 
Lung blocks, 126 
Mackenzie, 172 
Mac Nutt, 92 
Maggot trap, 122 
Malaria, 239 
see headings in text 
mosquito control for, 124 
Malta fever, 246 
see headings in text 
Manson, 235 
Manure, disposal of, 121 
Marriage, rate, 59 
statistics, 58 
Maternal hygiene, education in, 71 
under state, 159, 162 
mortality, prevention of, 71 
rates of, 69 
reasons for, 67 
reduction of, 68, 70 
Measles, 249 
see headings in text 
infant mortality from, 79 
Meat inspection, 138 
Medical examinations, school, 36 
forms for, 440 
inspectors, qualifications, 17 
Meningitis, epidemic cerebrospinal, 
253 
see headings in text 
Mental hygiene, 174 
Metropolitan Asylum Board, 63 
Midwives, course for, 400 
regulation, 67 
standards for, 68 
supervision, 68 
Mild cases, importance of, 182, 187 
Milk, 129 
bacteria in, 135 
certified, 133 
contamination of, 129 456 
INDEX 
Milk, disease transmission by, 185 
essentials in handling of, 132 
grading of, 132 
infant hygiene and, 73 
inspection of, 13, 408 
paste\irization of, 134 
Milk-borne diseases, control of, 130 
investigation of, 130 
Missed cases, importance of, 182, 
187 
Modes of transmission, sec under 
name of disease 
Morbidity rates, calculation of, 58 
uses of, 58 
report form for, 437 
reports, 56 
importance of, 186 
privileged information, 57 
uses of, 56 
U. S. P. H. S., 155 
Mortality, form for tabulating, 445 
of children, 89, 91 
see under name of disease 
Mosquitoes, anopheline, 241 
control of, 123 
Mumps, 257 
see headings in text 
Musca domestica, 122 
Naegli, 311 
National Tuberculosis Association, 
318 
Nationality and death rate, 62, 
65, 164 
Necator americanus, 225 
New York state health department, 
158 . 
Noguchi, 273, 277, 359 
Non-medical health officers, 16 
Notifiable disease reporting, 56 
Notification of disease, 186 
Nuisances, definition, 118 
duty of health officer in, 12 
forms for recording, 34, 439 
Nusiances, legal abatement of, 151 
control of, 150 
methods of abating, 118 
Office equipment, 37 
purchase of, 38 
system, 30 
Ophthalmia neonatorum, 203 
Organization of community for 
emergencies, 395 
Osier, 337 
Paratyphoid fever, 319 
see headings in text 
from meat, 141 
Park, 127, 208, 277, 325 
Parotitis, 257 
Pasteur, 193, 269, 281 
Pasteurization, check on, 130 
Pearl, 66 
Pearson, 60, 61, 87, 313 
Pediculosis, 259 
see headings in text 
Pediculus capitis, 259 
vestimenti, 259, 333 
Pellagra, 260 
see headings in text 
Permits, burial, 42 
Persons, not things, 186 
Pertussis, 357 
Philanthropic agencies, relation to 
health, 169, 174 
Phthirius inguinalis, 259 
Physician, private, relation to public 
health, 175 
Plague, 263 
see headings in text 
Commission, British, 265 
suppression of under U. S., 
155 
Plan of county health work, 365 
Plasmodium malariae, 240 
Ploetz, 60 
Plotz, 333 INDEX 
457 
Pneumonia, 269 
see headings in text 
infant mortality from, 78 
Poisoning, food, 137, 141 
Police power, 147 
Poliomyelitis, 272 
see headings in text 
Pollender, 193 
Popenoe and Johnson, 60 
Population, estimates of, 49 
sources of data, 49 
Poverty, relation to health, 164, 176 
Prenatal care, 68, 72 
nursing duties in, 381 
Pre-school child, health of, 90 
Privies, infection from, 108, 109 
Prophylaxis, medical, for venereal 
diseases, 354 
Prostitution, 347 
as health problem, 165 
objections to control of, 352 
regulation of, 352 
Public health nurse, in child care, 72 
in communicable diseases, 
379 
in educating mothers, 81 
in infant hygiene, 380 
in prenatal care, 72, 381 
in schools, 382 
instructions for, 378 
nursing technique, 391 
prenatal instruction by, 
381 
qualifications, 17 
support of health work, 24 
welfare, health work part of, 163 
Publicity, 13, 142, 144, 394 
Puerperal septicemia, 70 
Purchasing supplies, 38 
Quarantine, definition of, 190 
Rabies, 277 
see headings in text 
Rats, control of, 124 
poisoning of, 267 
Records, 30 
birth and death correction, 32 
communicable diseases, 32, 433, 
436 
dairy, 35 
cow, 35, 443 
health officer’s daily, 438 
laboratory, 36, 435 
mortality, 445 
necessity of, 38 
nuisances, 34, 439 
school examinations, 440 
size of, 31 
Recreation in venereal disease con- 
trol, 354 
Reed, 359 
Refuse disposal, 119 
Registrars, of births and deaths, 43, 
44 
Registration of births, 45 
of births and deaths, 41, 371 
of deaths, 42 
Regulations, state health, force of, 
157 
uniformity in state, 160 
Relation of health officer, to physi- 
cian, 1 
to public, 4 
Relative values, as affecting budget, 
22 
of health work, 18 
Reports, of health officer, 145, 372 
statistical, 374 
Rickets, 282, 301 
Rickettsia prowazeki, 332 
Rocky Mountain spotted fever, 282 
see headings in text 
Rodents, control of, 124 
Rosenau, 92, 196, 269, 302, 311, 312, 
425, 427, 429 
Rosenberger, 343 
Ross, 239, 240, 245 458 
INDEX 
Rotheln, 223 
Royal families, infant mortality of, 
87 
Rubella, 223 
Rubeola, 249 
Rural sanitation by U. S. P. II. S., 
155 
Sanitary inspection, form for, 439 
inspectors, qualifications, 17 
survey, water, 100 
Sanitation, general, 117, 368 
infant hygiene and, 74 
rural, 125 
Sarcoptes scabiei, 283 
Sawyer, 346 
Scabies, 283 
see headings in text 
Scarlatina, 285 
Scarlet fever, 285 
see headings in text 
heredity, effect of, 64 
in England, 63 
in schools, 95 
milk-borne, 131 
mortality record of, 63 
Schamberg, 198, 229, 295 
Schick test, technique of, 425 
Schneider, 18, 127 
Scholl, 195 
School children, causes of death 
among, 91 
form for medical inspection, 
36, 440 
hygiene, administration of, 95 
closing schools, 93 
control of diseases, 93, 94 
cooperation in, 25 
form for medical inspection, 
36, 440 
nursing duties in, 382 
sanitation of buildings, 97 
under state, 159, 162 
Score card, dairy, 35, 408 
Scoring dairy, method of, 408 
Sedgwick, 320 
Septic sore throat, 290 
see headings in text 
milk-borne, 131 
Sewage disposal, 109 
duty of health officer in, 12 
nethods of treatment in, 
110 
reduction of bacteria, 116 
supervision of, by state, 159, 
161 
Sewerage, 109 
Sex education, 353 
Sheppard-Towner Act, 71 
Simon, 213, 255, 291, 326 
Sludge, disposal of, 111 
Smallpox, 294 
see headings in text 
Smith, 172 
Social welfare work, definition, 163 
relation to public health, 
163 
Sources and modes of infection, 178, 
182 
Spirochaeta pallida, 343 
Spironema pallidum, 343 
State boards of health, functions 
of, 157 
secretary of, 158 
health agencies, aims of, 153 
functions of, 158 
laws, nature of, 156 
Sternberg, 269 
Stillbirths, 52 
causes of, 68 
Stokes, 341, 344 
Stream pollution, 109 
U. S. control of, 155 
Supplies, office, 36 
purchase of, 38 
Susceptibility to disease, heredity 
and, 65 
Suspected cases, control of, 187 INDEX 
459 
Syphilis, 341 
see headings in text 
infant mortality from, 78 
Taenia echinococcus, 303 
saginata, 303 
solium, 303 
Tapeworm, 302 
see headings in text 
Tetanus, 304 
see headings in text 
spore-bearing, 185 
Trachoma, 306 
see headings in text 
Training and qualifications, health 
officer, 15, 168, 174 
laboratory technician, 17 
medical inspector, 16 
public health nurse, 17 
sanitary inspector, 17 
Trask, 49, 56 
Trichinella spiralis, 309 
Trichinosis, 309 
see headings in text 
Tuberculin test record, 443 
Tuberculosis, 311 
see headings in text 
heredity, effects of, 64 
housing and, 126 
infant mortality from, 78 
milk-borne, 131 
nationality, effect of, 165 
Typhoid fever, 319 
see headings in text 
milk-borne, 130 
water-borne, 99 
Mary, 325 
Typhus fever, 332 
see headings in text 
in England and Wales, 63 
U. S. Bureau of Census, 153 
U. S. Bureau of Chemistry, 138 
U. S. Bureau of Education, 153 
U. S. Children’s Bureau, 01, 62 
child hygiene in, 153 
U. S. Dept, of Agriculture, 153 
U. S. Marine Hospital Service, 154 
U. S. Public Health and Marine 
Hospital Service, 154 
U. S. Public Health Service, Assis- 
tant Surgeons Gen- 
eral, 155 
divisions of, 154 
organization of, 154 
origin of, 154 
Surgeon General, 155 
U. S. Treasury Dept., 154 
Vaccination, smallpox, 296 
Values, relative, 18 
Varicella, 198 
Variola, 294 
Varioloid, 294 
Vectors of infection, 183 
Venereal diseases, 335 
see headings in text 
control of, 346 
control of patient, 356 
division of U. S. P. H. S., 156 
medical prophylaxis of, 354 
summary of control, 356 
Vice Commission, Chicago, 349 
Vital statistics, 47 
definition, 47 
errors in, 48 
functions of state in, 158, 160 
guide to health activities, 162 
improvement needed in, 170 
uses of, 48 
Wassermann test, 345 
Wastes disposal, 117 
duty of health officer in, 12 
Water, in transmission of disease, 
99, 185 
proof of pollution of, 100 
softening, 102 460 
INDEX 
Water-borne outbreaks, character- 
istics of, 99, 185 
investigation of, 100, 161 
Water supplies, 99 
contaminated, control of, 
101 
contamination, kind of, 102 
duty of health officer in, 12 
emergency treatment, 101 
ground water, 102 
laboratory examination of, 
105 
local control of, 368 
protection of, 191 
sanitary qualities of, 99 
Watpr supplies, supervision of, by- 
state 159, 161 
surface, 102 
treatment of, types, 103 
Whipple, 49, 183 
Whooping cough, 357 
see headings in text 
infant mortality from, 78 
in schools, 95 
Williams, 277, 325 
Wittwer, 262 
Yellow fever, 359 
see headings in text 
Yersin, 263