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The Columbia University Libraries reserve the right to refuse to accept a copying order if, in its judgement, fulfillment of the order would involve violation of the copyright law. Author: Bureau of Municipal Research... Title: IVIaking a municipal budget Place: [New York] Date: [1 907] Qs-&imfc' MASTER NEGATIVE » COLUMBIA UNIVERSITY LIBRARIES PRESERVATION DIVISION BIBLIOGRAPHIC MICROFORM TARGET ORIGINAL MATERIAL AS FILMED - EXISTING BIBLIOGRAPHIC RECORD RESTRICTIONS ON USE: Lsiness D684 B894 Bureau of municipal research, Nexo York, Making a municipal budget, functional accounts and opera- tive statistics for the Department of health of Greater New York; prepared and published by the Bureau of municipal research, New York, 1907 ... [New York, 1907, 171 p. Incl. forms. 22i«". r L New York (City) Health dept. 2. Municipal finance. 3. Vital sta- tistics. I. 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'^. € 4^ ■^^ .V** .!< ^< >?, •v « .<' y> if^ ce ^ ¥d. f^ ^^ m O O ■o m "0 OL,Ti > C Cd I TJ ^ m o m A* 4P '\^ C c.^ ^♦^ »-• to (J1 3 3 3 3 a- «8 001^4 ii 8 3GW iiiel ♦ a A €^ ic /[e^e^inch sc DAMAGED PAGE(S) vlAKING A MUNICIPAL BUDGET ^ % 1 I FUNCTIONAL ACCOUNTS AND OPERATIVE STATISTICS FOR THE DEPARTMENT OF HEALTH OF GREATER NEW YORK ». • «i PREPARED AND PUBUSHED BY THE BUREAU OF MUNIGIPAI, RESEARCH New York, 1907 A limited number of copies of this report may be obtained at 50 CENTS EACH IISTIDEX Accounts, department of health, 1906 25-2* Defects in and revision of 10, 27-3 Segregation ledger 27, 30, 156-16' Cost vs. disbursement, expense vs. expenditure accounting .10, n, 27, 28 Commissioners of, and service records 21 Aldermen demand classification of budget, 1906 1 1, 36 Budget : effective publicity through 3,5 Defects in and revision of 6, 9," 30 Advantages of classification 7, 1 1, 12, 36, 37 Conference committee on revisiow. 0!,^ X908 . , 1 1 Estimates should be explained. . . n, i^ 16 Bureau's brief for segregated budget, 1906. 1 1. 34, 35, 39 Titles of appropriations, 1906, 1907, 1908 38-44 Service reports in connection with. 15, 16 Bureau of Municipal Research : history, purposes Cover, 5 Trustees and administrative council ' 3 Brief for segregated budget, 1906. u, 34, 35, 39 Conference committee with department of finance, 1907 ij Death rate vs. case rate as test of public health 22 24 Control through accounts and records 12, i^^ 27-30, 32 Estimate and apportionment, board of .11, 34, 35, 37 Exhibits (bmitted from abridged edition) 1 Bureau's brief for segregated budget, 1906 34, 35 2 Resolutions, (a) board of aldermen, and (b) board of estimate and apportionment, 1906, favdring segregated budget 36, 37 3 Appropriation titles, health budget, (a) 1906, (b) suggested by Bureau for 1907, (c) actual, 1907, (d) 1908 38-45 4 99 blank forms for health report. 46-153 5 Suggested form for report of expenditures.. 154, 155 6 Segregation ledger, proposed classification 156-165 7 Scoring cards : dairies, creameries, milk shops 166-171 Function as basis of budget, accounts and records 9-14, 26, i8, 29, 30 Health, department of : functions of 7, ^3? 14 Public interest starting point for budget revision 7f 9, 34i 35 Reports and records in 1906, and revision of. lo-ta, 15, 17-19, 21, 23, 25, 46=-i53 , Ledger segregation, 1906, 1907 27-30; 156-165 Milk inspection, scoring cards, etc 56-67, 166^171 Reports and records of service rendered : publicity 5, 6 Requisite to intelligent budget 14-16 DiflSculties of securing accuracy 19-21 Of department of health 10, 17-19, 25 As revised in 1907, method of devising 12, 21, 22, 46-153 Lead to improved organization .^ . . . ,^. , 30, 31 School inspection^ medical examination, etc 15, 16, 92-105 MAKING A iVlUNICIPAL BUDGET PREPARED AND PUBLISHED HY THI-: BURKAU OF MUNICIPAL RESEARCH New York. 1907 A limited number of copies of this report may be obtained ai 50 CENTS EACH Coluinbta (Hnitif wttp mtlieCtlpoflrtogork LIBRARY MAKING A MUNICIPAL BUDGET ^4* ' ^ FUNCTIONAL ACCOUNTS AND OPERATIVE STATISTICS FOR THE DEPARTMENT OF HEALTH OF GREATER NEW YORK PREPARED AND PUBLISHED BY THE BUREAU OF MUNICIPAL RESEARCH New York, 1907 A limited number of copies of this report may be obtained at 50 CENTS EACH 'i )7Uc ■ /^/^ A' ^^ z^ PREFACE This is the first of a series of reports by the Bureau of Municipal Rc^ search on the general subject of Budget Making. It is addressed to tax- payers who wish to know what benefits their taxes buy and what community needs are not provided for; to municipal officers who wish to obtain public support for efficient, far-seeing administration ; to civic bodies, who aim, by informing public opinion, to improve municipal government; and to phil- anthropists seeking opportunity for productive fields of benefaction. The successive steps in the inquiry are set forth chronologically for the light they throw on methods of municipal research and of co-operatioit with city officials. BUREAU OF MUNICIPAL RESEARCH Trustees Edwin R. A. Seligman, Chairman Frank Tucker, Vice-Chairman R. Fulton Cutting, Treasurer Richard Watson Gilder George McAneny Albert Shaw Carroll D. Wright Administrative Council William H. Allen, Secretary Henry Bruere, Director Frederick A. Cleveland, Technical Director Rufus E. Miles William R. Patterson Paul C. Wilson ^-ir Introduction No document can tell in such condensed form so many significant facts about community needs and govern- ment efforts to meet those needs as a properly construct- ed budget. In view of this fact it is rather surprising that budget making as a method of publicity has here- tofore been generally neglected in American cities. Per- haps it is because we are accustomed to think of the characteristics of publicity rather than its source or method. We describe certain qualities of publicity such as intermittent and constant, explosive and cumulative, whispered and advertised, ineffective and effective; but rarely have we set over against each other, the publicity about government that originates with private citizens, newspapers or magazines and that other publicity about government which originates with governing officials through public statements and published reports. The publicity of the latter kind that originated with New York City^s officials in 1906, more particularly with its budget makers, only added to confusion and helplessness on the part of the public. Because the current records and reports of various departments were not so kept as to disclose their mean- ing readily, the greater part of this Bureau's* effort from January, 1906, to August, 1907, has been directed to securing methods of accounting for moneys spent and for recording work done that would clearly and promptly show the results of municipal activity in its various phases. Its emphasis upon system rather than personnel, upon provable results rather than pretentions, has been due to the double conviction, (a) that inefficiency will almost invariably be found together with unbusiness-like organization and methods; (b) that the most effective Publicity by Officials Original Sources of Effective Publicity ♦Known as the Bureau of City Betterment, January, 1906, to May 3, 1907; then Incorporated as the Bureau of Municipal Research with the following program: To stromote efficient and economical municipal government ; to promote the adoption of scientific methods of accounting and of reporting the details of municipal business, with a view to facilitating the work of public offi- cials ; to secure constructive publicity in matters pertaining to municipal problems ; to collect, to classify, to analyze, to correlate, to interpret and to publish facts as to the administration of municipal government. The Bureau will gladly answer questions that may be prompted by this report Sadget iStady -Astguat, Methods <«f Urging Sudget SteXorm MAKING A MUNICIPAL BUDGET publicity must proceed from records and accounts de- vised for the purpose of informing responsible officers and the public as to government results and community needs. In its study of street paving contracts, depart- ment of street cleaning, city owned houses, and the ad- ministration of the office of the president of the borough of Manhattan, it learned by a careful analysis of condi- tions that the city's method of attending to the various duties involved was calculated to conceal and promote inefficiency, confusion and corruption. Facts, and con- clusions based upon facts, found from the start a cordial, appreciative welcome at the hand of city officials, civic leaders, editorial writers and the general public, and led invariably to improvement of conditions described. It seemed advisable, therefore, in August, 1906, to call at- tention to the city's hit-or-miss method of making its budget; i. e., of distributing its annual tax levy of $130,- 000,000, voted for the discharge of those duties that have grown out of common acts, common needs and com- mon properties. It would have been easy to criticise on theoretical grounds the existing method of budget making. The community would not have been surprised to be told that $130,000,000 was voted away annually without prop- er questions being asked as to the services to be pur- chased. All observant citizens knew that department heads asked for more than they needed in the hope of getting a substantial increase in spite of the arbitrary horizontal cut of ten to twenty per cent almost invariably made by the board of estimate and apportionment. Num- erous stories could have been told of money asked and voted for one purpose that had been used for entirely different purposes. Next year's revenues were mort- gaged to do this year's work, but the public did not realize that this "penny wise, pound foolish" practice re- duced year by year the purchasing power of the dollar paid for taxes. Supplementary appropriations and trans- fers from one fund to another concealed the weaknesses of the bucTget, and rarely came to light in the succeeding budget; consequently, popular phases of work were em- phasized at budget sessions, and appropriations less popu- lar or questionable were rushed through at regular meet- i ^ ■H 1 HEAWH BUDGET, NEW YORK CITY ings of the board of estimate and apportionment when crowded calendars prevented adequate consideration. No serious doubt would have been expressed had the Bureau claimed that at least $10,000,000 could be saved annually by introducing business-like methods of budget analysis. But such a discussion of the abstract principles that should govern budget making even when illustrated by existing defects would have resulted in little if any action. Real- izing this, and appreciating the educational advantage of an object lesson, the Bureau set out to prepare a budget for one department in a way that would demonstrate the value of a clear showing of just what work it was proposed to do with the funds requested. For reasons of expediency it was decided to present the claims of the health department, which happened at this time to be in particular need both of funds and of public support. In thus approaching budget making from the stand- point of health administration, the Bureau aimed to avail itself of the line of easiest access to public attention and conviction. No one has the courage to defend inefficient health administration. No one says "Let well enough alone" when told that health officers are neglecting their duties. Everyone has a vital interest, that he can be easily taught to picture, in the adequate protection of public health. Finally the department of health was in position to make out a clear case before any jury ; it had definite work to do and could clearly describe why that work should be done. Therefore, it was decided to use the appealing power of health needs to illustrate the principle that should govern budget making for all de- partments. As is told on page 11, the fiscal authorities responded by committing themselves at once to the propo- sition that henceforth in New York City money shall not be voted until the fiscal authorities and the public are told for what purposes the money will be used, how much was used for similar purposes last year and why the decrease or increase, if any, in the amount of work proposed. The board of health was prepared to welcome the Bureau's request for co-operation in framing a health budget based upon a clear analysis of the city's health needs as shown by the department's experience. During Approach via Health Needs 8 Why Health Officers Welcomed Suggestion MAKING A MUNICIPAL BUDGET the winter and summer of 1906, the pubHc mind had been greatly agitated over various conditions said to be men- acing public health. Milk was dangerous because con- taminated; lodging houses were spreading tuberculosis and other diseases ; grave fears were entertained because the sources of water and ice supply were contaminated ; hundreds of thousands of children were said to be in need of medical, dental and ocular care; streets were littered with rubbish; garbage was tardily collected; black smoke was polluting the air day and night; an anti-noise society became necessary ; impure drugs, meats and other foods were sold in violation of state and na- tional laws. The department of health was in the habit of meeting complaints in two ways: (i) It protested that it had insufficient funds. (2) To correct the evils complained of most bitterly in the morning it borrowed men engaged in correcting other evils, only to learn in the afternoon that Paul had been crippled to help out Peter. A strong appeal by a private society led the mayor be- fore leaving on his vacation to ask the unanimous con- sent of the board of estimate and apportionment to act upon a resolution giving the department of health $100,- 000 for hot weather emergency work ; by August it was obvious that the greater part of the money had been absorbed by activities not contemplated in the appropria- tion. For several years prior to the inquiry the board of estimate and apportionment in fixing the amount of the health budget had made a cut of 18% to 42% in the estimates presented by the board of health. In doing this the fiscal authorities had made no attempt to determine the exact needs of each of the many functions exercised by the department of health. They had required no statement of cost of conducting these several functions, and no contrasting exposition of work accomplished. Arbitrarily assuming an exaggeration in the department's estimate the fiscal authorities arbitrarily shaved down the requests in determining the amount to be apportioned in the budget. While the department's experience justi- fied the hope that supplementary appropriations would be made and revenue bonds issued, it never knew in what amounts these additional funds would be granted or how far short they would fall of the department's needs. The i. • -'^ /?-• f HEALTH BUDGET, NEW YORK CITY doling out of appropriations bit by bit through the year prevented the department from utilizing to the best ad- vantage what funds it did receive. In laying out its plans of work at the beginning of each year, the depart- ment was placed in the dilemma of immediately curtail- ing its activities to correspond with its limited appropria- tion, or of continuing its work on a scale larger than the budget justified, on the chance of securing bond issues when the regular appropriation was exhausted. Under such circumstances, the department of health could adopt no far-reaching policy or plans with any assurance of car- rying them out. In other words the health department lived from hand to mouth, borrowing from July to do April's work, prevented by budget methods from being efficient and economical, from taking at each season the stitch in time that saves nine. For the foregoing rea- sons the commissioner was prepared to see the force of the Bureau's suggestion that the best way to increase funds and to earn public confidence was to show clearly what the community needed and to place squarely upon the fiscal authorities the responsibility for failure to un- dertake the entire amount of health work required. After consultation with the Mayor, Commissioner Dar- lington agreed to the plan of the Bureau and cordially facilitated its execution. The staflF of the department co- operated in every way with the Bureau's investigators. The medical officer, Dr. Herman M. Biggs, the commis- sioner's chief assistant, Dr. Walter Bensel, and various division heads welcomed the obvious opportunity to strengthen the department's case and contributed most valuable suggestions. Proposed Sttidy of Health Department The statement of the health situation contemplated by the Bureau aimed to cover the following points : (i) The functions or lines of activity maintained by the department in answering the questions : What kinds of work is the department trying to do; what forms of danger is it planning to guard against? (2) The service rendered in each during the latest period for which reports were available. Penalties for Hit-or-Mlss Budget Methods Elements to be Studied lO Service Data Not Obtainable Cost Data Not Obtainable MAKING A MUNICIPAL BUDGET (3) Cost of maintaining each activity or function. (4) A comparison of service with cost in each activity or function. (5) Proposed expense for each activity or function for the ensuing year with detailed estimates and compari- sons and with reasons for changes. Before an accurate statement of the functions and ac- tivities of the department could be made, an extended inquiry was found to be necessary, inasmuch as the or- ganization, — the assignment of duties, and the distribu- tion of responsibility among officers and subordinates- was not explicit and did not appear on the records. The reports and records of service performed were ill- adapted to meet the demands for information needed in budget making. The prevailing forms of annual report did not present all the significant facts; the relation be- tween facts given was not made clear; the items were sometimes in terms ambiguous to anybody but the depart- ment officials, not infrequently being understood by no one but the clerk who compiled them; the figures were obtained from fragmentary records; statements of fact that related to each other were scattered through the re- port, their value being lost because there was no index; when found, the data were in such different form that lomparison was difficult or impossible. Likewise the accounting system of the department did not readily lend itself to obtaining information as to cost. The classi- fication in use was by "funds'* or "appropriation ac- counts" which in most cases did not represent clearly de- fined functions or activities of the department. For ex- ample, out of the school inspection fund were paid not only the medical inspectors of schools but the school nurses and the so-called summer corps, consisting of phy- sicians and nurses engaged in house-to-house visits to dis- cover babies suflfering from summer complaint, and to instruct mothers in their care. Furthermore, the fund or account to which an item of expenditure was charged did not necessarily indicatt what function of the department actually received the benefit of it. In salary accounts, an employee's salary might be charged to a function to which only a part or none of his services were devoted. Sixty-eight physi- I.' * "^ j/' * ', I f-^ ; HEALTH BUDGET, NEW YORK CITY cians, for example, having been charged to "school in- spection" were never engaged in school inspection. Simi- larly supply accounts failed to show in what proportions the different activities consumed supplies that were pur- chased in bulk. Even when fund did correspond with function — when supplies were used only by the activities to which they were charged — the expenditure shown in the supply accounts frequently did not represent true cost for the reason that the books showed money paid out for supplies and not supplies used; to assume that sup- plies purchased are supplies consumed is analagous to assuming that money deposited in a savings bank is money spent — a fallacy apparent to the novice. From the financial records used in August, 1906, a complete and accurate statement of costs for the different functions could not be obtained. In view of these difficulties it was seen to be impossible in six weeks to formulate a restatement of the entire de- partmental estimate, together with supporting statements of cost and service, in time for the budget for 1907, which must be ready for consideration by the board of esti- mate and apportionment in October. It was, however, found to be feasible, with some inves- tigation, to classify salaries and incidental expenses ac- cording to function, that is, according to departmental activities; and since salaries and incidental expenses constituted about two-thirds of the total expenses of the department of health it was determined to present a classified statement of them to the board of estimate and apportionment to function, that is, division of work. The resolutions of the board of estimate and apportion- ment and the board of aldermen are repeated (Exhibit 3) because it is considered that in the evolution of the American budget those documents will prove to be epoch- making. That the purpose to put the principle into operation has not been lost sight of is evidenced (a) by the circu- lar letter issued May 28th, 1907, by the finance depart- ment to the heads of departments, calling their attention to the above resolutions and requesting them to confer with the comptroller on the form of their estimates, and ^b) by the comptroller's appointment of a joint com- II Expedient for Budget of 1907 Success of Expedient 12 Improved System of Accounts Revised Service Records Adopted MAKING A MUNICIPAL BUDGET mittee of representatives of the Bureau and the depart* ment of finance to prepare classifications for the budgets of several of the major departments, i. e., water supply, gas and electricity; Bellevue and allied hospitals; de- partment of street cleaning; health department; police department. Rcof gfanhation of Administrative Records and Accounts After the adoption of the budget for 1907, the Bureau, pursuing its original purpose, suggested that the depart- ment make such changes in administrative records and accounts as would enable it to report readily and ac- curately both service rendered and the cost of maintain- ing each function. In April, 1907, following numerous conferences, important modifications in methods of ac- counting were recommended, (a) revised classification of accounts corresponding accurately to functional activities, in which disbursements should be charged strictly ac- cording to their use; and (b) a system of store accounts which, in connection with inventories, would render state- ments of cost possible for any desired period. The form- er recommendation, in its main lines, has been adopted and is being put into effect for the coming budget. The second recommendation has not yet been adopted. (See page 29). The problem of modifying the service re- ports and records, it will be seen, had to be approached somewhat differently from that of the accounts. In the latter, it was perfectly clear what should be shown, i. e., the costs properly chargeable to each function. The only question was as to the mechanism by which to show it most satisfactorily. With the service reports, however, the primary question was : What are the significant facts that should be shown ; by what standard can success or failure be judged in each line of activity? The question of mechanism was here secondary. A series of con- ferences with the various executive officials of the depart- ment was therefore necessary to determine the essential facts of its activities. The result of these conferences was the series of tabular forms presented in Exhibit 4 of this pamphlet, which have been adopted by order of the commissioner for the purposes of the annual report. The •f • HEALTH BUDGET, NEW YORK CITY changes in office records necessary to meet the new re- port forms are now in progress. With the information thus provided for, the Bureau believes that the public, through its immediate financial representative, the board of estimate and apportion- ment, will be enabled to render a far more intelligent answer to the annual question : How much ought New York City to spend for the purpose of maintaining the public health? Analysis of Lines of Activity It is tlie duty of the department of health, as out- lined by the charter, to provide by suitable measures and by means of the sums appropriated to its uses, conditions looking *'to the preservation of human life, or to the care, promotion and protection of health" in the City of New York. The lines of activity which the department is maintaining constitute its answer to the question: "What are the health needs of the city that are most im- portant to meet ?" The need that the milk supply be pure is recognized in the inspection of milk; to tlie need for reducing the prevalence of tuberculosis, the department's response is the maintenance of district inspection, clinic and sanatoria. The department is, of course, aware of needs which have not yet been met by any organized ef- fort on its part, owing to the fact that its resources are not unlimited. It is fair to say, however, that the activi- ties now maintained are an expression of its judgment as to the measures most immediately necessary to the public health. The lines of its work that constitute direct publiq ser- vice are as follows: General sanitary inspection Milk inspection Food inspection Inspection of mercantile establishments Lodging house inspection Shore inspection District medical inspection of contagious diseases Medical inspection of school children Summer corps 13 General Functions of Department Functional Activities M Administrative Divisions MAKING A MUNICIPAL BUDGET Vaccination Disinfection (including goods wagon service) ! Inspection of animals District inspection of communicable diseases The tuberculosis clinics .' Willard Parker and reception hospitals Riverside hospital Kingston avenue hospital (including ambulance service) Otisville sanatorium Trachoma hospital Removal of dead animals, offal and night soil Research laboratory Chemical laboratory ' Vaccine laboratory ! Diagnosis laboratory Department stables Drug laboratory The executive and clerical divisions of the department are the offices of the Commissioner Secretary General medical officer Sanitary superintendent and assistants Registrar of records and assistants Chief clerk Assistant chief clerks Assistant corporation counsel In each of these various lines of activity there is the double problem (i) of arriving at costs and (2) of re- porting service results in such form as to render these, as far as possible, definitely measurable and comparable with costs. Reports of Service Results The answer to the question, "What expense is in- curred to maintain a given activity?" tells little without the answer to the corresponding question, "What ser- Tice is rendered by means of that expense?" Whether administration has been economical or wasteful can be determined only by contrasting cost with service results. • * 1 J s..< HEAI^TH BUDGET, NEW YORK CITY And the more important question, "How far are the health needs of the city being met, irrespective of costs ?" can be answered only through the reports of service. Wherefore, the necessity for reporting service results, especially at the time of considering the budget. Recognition of this necessity is found in various pub- lic papers. The annual circular letter issued to heads of departments by the board of estimate and apportion- ment calls for full explanation to accompany the esti- mates, stating the reasons for any increase or decrease in the amounts. The following extracts from the letter of transmittal accompanying the estimate of the board of health for the year 1906 are to the same point: "The board of health most urgently requests your critical consideration of this estimate, for they feel that the more you investigate the requests for the various funds the more you will be convinced that they are reasonable and necessary, and that the sums, if so appropriated, will not only be used wisely but their use will result in great and demonstrable benefits to the city.*** While it may appear to your Honorable Board that the sums ex- pended by the department of health are large, the board of health feels confident that a careful study of the results attained will convince you that the cost is really insignificant as compared with the benefits secured. **The board of health is con- fident that the ratio of increase in the annual budget to the decrease in the death rate will surely be main- tained should your Honorable Board consent to the award of our estimate as herewith transmitted." In practice, however, department estimates reveal little or no systematic attempt to demonstrate or justify their services or needs. A typical example of the "explana- tion" accompanying department estimates is the follow- ing statement in the budgetary estimate of the depart- ment of health for the year 1907 : "The increase of $39,600 for medical school in- spection, as shown above, is requested to pay the salaries of thirty-two new medical inspectors, at $1,200 each, distributed among the various boroughs, as indicated above, and of one additional nurse, at 15 Necessity of Reporting: Service Necessity Recognized No Service Reports In Connection With Budget i6 ll Possible Service Report To Support Estimate MAKING A MUNICIPAL BUDGET $i,20o, in the borough of Manhattan. These are required to keep pace with the constantly growing school population throughout the city.'* How the estimate of just thirty-two inspectors and one nurse is arrived at does not appear. No statement is presented to show the results of the work previously performed by school inspectors or to prove the necessity of any additional inspectors. It would require little more space and would convey far more information, to present a brief table like the following: 1907 1908 (Actual) (Estimated and Proposed; Total registration in public schools .. ^500,000 *6oo,ooo Number of children examined 200,000 6oo,oc>o Percentage of total reg-istratlon 40 100 Number needing treatment. . .* 60,000 180,000 Per cent ag'e of those examined needing treatment SO 30 School physicians So i6o 'The estimated increase in the number of inspectors necessary to examine as proposed all the children in the public schools could be set forth as follows : With the present number of inspectors, 40% of the children have been examined; to examine all, an increase of 150% in available service is therefore necessary; with the pres- ent assignment of schools, inspectors spend on an aver- age only about 60% of their time in actual service, the remaining 40% being consumed in traveling about. With an increase of 100% in the number of inspectors, the time wasted in traveling could be cut down from 40% to 10% of the time of each inspector, each therefore performing 50% more work for the same compensation * as at present. In other words, where an inspector now examines 2,500 children a year, he could then examine 3,750 a year. An increase of 100% in the number of inspectors is therefore requested, with which resources the department pledges itself to examine all the children in the public schools." Such a request expressed in definite terms would, if the appropriation were granted. \i^. X • The figures given in this paragraph for purposes of illustration are entirely fictitious HEALTH BUDGET, NEW YORK CITY become a matter of record against which might he checked up the actual performance of the following year. It might be supposed that the statistics of service, though not presented (perhaps because not demanded) with the departmental estimate, would certainly be found in the annual departmental report. An examination, however, of the last published annual report of the de- partment of health (that of 1904) shows no such in- formation. Out of some fifty pages of statistics of ser- vice presented in the report, twenty-two are devoted to hospitals, seven to a list of vacated premises and four to legal action taken on violation of the law, leaving thus only about ten pages to the important work of the divi- sion of inspections and the division of contagious dis- eases. The amount of space devoted to the diflFerent lines of work, it is seen, is not in any way proportioned to their relative importance. Moreover, the statistics re- lating to any activity have to be sought through the en- tire report, being scattered and unindexed, sometimes €ven being impossible of identification from lack of titles. The figures for the various boroughs, if .given at all, are not always in similar form, thus rendering comparison impossible, either of one year with another in the same borough, or of borough with borough. Of the facts nec- essary to estimate the results accomplished, essential items are not infrequently missing. For example, the statistics of milk inspection in the annual report for 1904 are in several sections as fol- lows : Page 67 Number of inspections (unobtainable, being included with inspections of fruit, food, meat, etc., in a grand miscellaneous total) 587,682 Number of specimens of milk ex- amined i5i22 Number of specimens of milk col- lected for analysis 2,097 Number of quarts of adulterated milk destroyed 4^53^ Number of analyses i^oii « Number of permits issued i5>29o Number of arrests 56^ 17 Annual Reports Defective In Presenting Service Results i8 il Illustrations of Defective Reportins MAKING A MUNICIPAL BUDGEl Number of persons held on bail 373 Number of persons discharged 25 No indication is given as to whether those facts relate to one borough or to the entire city. Whatever the part of the city to which they do relate, the information be- comes of little value from the lack of the important item — number of milk inspections. Without this figure it is impossible to infer whether a store is, on the average, inspected once a week or once in six months. The num- ber of permits is furnished, but not the number revoked ; no indication is available of the average number in force which the inspectors should be held responsible for in- specting. Why the number of analyses is more than one- half the number of specimens collected for analysis is a matter of conjecture, as is also the number of analyses showing adulteration and therefore necessitating further action. Finally, nothing is stated as to what became of the 167 persons arrested who were neither discharged nor held on bail. The second group of statistics relating to milk inspec- tion is on pages 79 and 80, as follows : Work Performed by Milk Inspectors Number of inspections 40,169 Number of specimens of milk examined 47,624 Number of specimens of milk collected 4,212 Number of quarts of adulterated milk destroyed. .28,621 Number of arrests 408 Number of persons held on bail 338 Number of persons discharged 19 Number of persons dismissed i Number of persons acquitted 2 Number of sentences suspended 52 Number of trials 406 Amount of fines $7,340 As before it is not stated whether these facts refer to one borough or to the entire city. A comparison of the figures, however, (p. 79 with 67), leads to the supposi- tion that (the totals being larger) the latter group ot inspections, specimens, etc., relates to the entire city, and the former group to one borough. The number of ar- rests, however, being smaller, indicates that the number of arrests given in the first group probably includes some *, HEALTH BUDGET, NEW YORK CITY relating not only to milk inspection, but to other lines as well. The number of permits issued, revoked, or in force, is not mentioned, nor the results of analyses of specimens stated. On page 153 appears the single item: Permits to sell milk 2,781 Since this item appears in a table directly above the signature of the chief sanitary inspector for Manhattan, it is to be supposed that the number refers only to that borough; the question arises, however, when comparing this figure with the number of permits issued as given above, 15,299, how it happens that Manhattan, with over half the population, appears to have issued only a little over one-sixth of the entire number of permits. It does not appear in what boroughs the inspections were made ; no basis is given for estimating the average frequency of inspection of stores or of wagons; nor is the number of discovered violations related to the frequency of inspec- tions. The endeavor to obtain the facts of service results for budget purposes encounters two main difficulties which should be recognized at the outset, the first relating to definiteness and the second to accuracy For budgetary purposes it would be most satisfdctory if the lesults fol- lowing from the expenditure of certain sews of money were as definitely measurable as the product of a silk mill or a nail factory, but as a matter of fact, it is quite otherwise. It is often difficult and sometimes impossible to ascertain exactly what are the service results from given expenditures. As to the immunization of well per- sons exposed to diphtheria by the administration of anti- toxin, it can readily enough be stated that only a very small number contracted the disease; but, obviously it is quite out of the question to state how many cases were averted, because there is no means of knowing how many cases would have occurred without the injections. For much of the work of the department of health, being in greater or less degree of a preventive character, it is impossible to state absolutely the results. Who can assert positively how many cases of scarlet fever were prevented by means of quarantine or by removal of cases to hospitals ? In such cases the only recourse is to show 19 Difficulties of Securing Accurate Service Reports 20 I !; Means Suggested for Meeting Difficulties MAKING A MUNICIPAL BUDGET by means of a table covering a series of years that there has been, parallel with the increased activity of the board of health, a gradual decline in the number of cases oc- curring ; that the epidemics, when they do come, are less serious than formerly. Many of the activities of the department, however, are capable of measurement. Children with adenoids are much more likely to succeed in their school work, if properly operated on, than if left untreated ; here results can be stated in percentage tables. Each line of activity, it was found, demands a standard of its own, by which its achievement can be fairly judged. A further limitation upon the value of service reports is imposed by the necessary method of their formulation, which is substantially as follows: Either the depart- mental employee or his immediate superior (a foreman of some kind) makes a report of work performed which becomes a part of the office records. These are sum- marized and re-summarized for the purpose of each suc- cessive superior official to assist him in his administrative control over his subordinates. The final step is the re- port of the commissioner to the public, represented by the mayor, upon the work of the department as a whole. Throughout there is constantly in operation the tendency on the part of the one rendering the report to present the case in a light as favorable as possible to himself. The tendency may vary in degree from nothing more than a discreet failure to emphasize disagreeable facts to an actual falsification of the report. To reduce to a mini- mum the possibility that reports will conceal or withhold facts damaging to the employee, division or department that makes the report, two precautions are needed : (i) The forms of administrative record and report should, so far as possible, be capable of ready proof and verification. (2) They should be currently verified through exam- ination and comparison at department headquarters. (3) Inspection by the department of its subordinates should be such as to ascertain whether work reported on records to have been done, is actually done ; which result requires that the report be specific as to time, place, etc. With few exceptions, a department official, who is hon- estly desirous of furnishing efficient service, will admit s *, HEALTH BUDGET, NEW YORK CITY . 21 the necessity of such reports and will co-operate in de- vising them; with few exceptions, officials who profit from misstatements will make a show of candor and will lack the courage to oppose adequate checks on records of work done. (4) The commissioners of accounts, bureau of statis- tics, comptroller, mayor, or whatever office is financially responsible to the tax payer, should periodically investi- gate departments to see whether or not proper methods of verification are in force, and whether these adequate tests are constantly applied. In other words, there should be an examination of service records analagous to the examination of accounts known as audit, thus provid- ing each department head with administrative control over his subordinates, and the city as a whole with ad- ministrative control over department heads. By these two means, the reports of service rendered can be made sufficiently accurate to serve as bases of estimate in fram- ing a budget. Having clearly in mind the above mentioned difficul- ties the eflFort was made to provide for service reports which could be correlated with facts of expense as a basis for the health budget. The two steps in the process were (i) to ascertain the significant facts and (2) to de- vise forms which would present these facts most clearly with a minimum of eflFort to the reader. To each of the lines of activity of the department the following scheme was applied: Analysis Specific object of each line of work; also the ultimate health object, if that can be stated. Activities designed to accomplish that object. Relation of activities to object. In what common terms can they be com- pared? Are there any definitely measurable health facts which can be shown to follow as a result of the activities in question? If not, how strong a presumption can be estab- lished? Whenever the object can be stated in measurable terms, independently of the amount of work done, there should be such statements, to show how far the object is being achieved. Method of Devising Service Reports MAKING A MUNICIPAL BUDGET Whenever the object is not thus independently measurable, a presumption as to the degree of success should be established by means of a logical arrangement of the statements of amount of work done. From such analysis of the several lines of work, the forms of report were devised. Some of those are composed of facts already presented by the department, but rearranged; others, while based on the system of rec- ords now maintained in the department, are somewhat fuller in state- ment than those of the present annual reports. In some instances they re- quire new methods of record keeping, though not necessarily additional labor. The form in which the facts are presented are specially designed to facilitate comparison of different years, each borough by itself, and, so far as conditions justify, borough with borough, it being only through such comparison that full value can be derived from statistics of service. For some of the administrative divisions mentioned on page 13 it will be observed that report forms are not included, though of course all of them are provided for in the system of accounting. The purely executive and clerical divisions, while necessary to the achievement of results, are not susceptible of accurate measurement in any form available for an annual fcport. Their efficiency must be judged by special examinations. Hence, no tables are suggested for the general administrative offices of the com- missioner, secretary of the board, general medical officer, sanitary superin- tendent and assistants, registrar of records and assistants, chief clerk and assistants, the assistant corporation counsel, or drug laboratory. Consideration of several of the lines of work raises points which require fuller discussion. It will be noticed that the tables dealing with infectious diseases have made use of the number of cases reported as a basis of com- parison, rather than the number of deaths. It is a com- mon practice among boards of health to present as evi- dence of the success of their work figures showing a diminishing general death rate. The main reason for this is doubtless that more accurate figures can be ob- tained for the general death rate than for any other standard. It is virtually impossible, in New York City, to escape reporting deaths; while of cases of contagious and communicable diseases actually occurring and rec- ognized as such, the proportion reported may vary con- siderable, borough with borough month with month. These are, however, several inaccuracies in judgments as to efficiency of health boards based upon changes in the general death rate: X>eath Rate as Criterion of Public Sealth ^ ♦ 4 t '%.' HEALTH BUDGET, NEW YORK CITY (i) During the last several decades there has been in civilized countries a steady decline in the general death rate; hence a decline of itself cannot in any particular locality be quoted as evidence of the efficiency of the local health body. (2) Case fatality differs widely among different dis- eases and even in the same disease under different cir- cumstances; hence the death rate, either general or for any single disease, cannot accurately indicate the amount of sickness. (3) Because the bulk of the work of a department of health is not curative but preventive, far reaching reme- dies might not immediately be reflected in the reduction of mortality. As a matter of theory, it is evident that the success of preventive work is measured by the degree in. which prevalence of disease (morbidity) is diminished ; success in curing disease is measured by a decreasing proportion of cases resulting in death (case fatality) ; while, strictly speaking, the death rate (number of deaths per 1,000 or 10,000 of population) is an index of neither prevention nor cure. It becomes a question, then, of how far the number of cases reported can be made a reliable index of the number of cases actually occurring. The chief possibilities of statistics being inaccurate would seem to be the following: (i) Not all the cases of any disease actually occurring and recognized as such are reported by physicians to the department of health. The proportion a reported va- ries: (a) according to the seriousness of the disease, i .e., the likelihood of the physician's being detected, in the event of the patient's death, in not having reported the disease. There is nowhere the completeness of reporting in measles that there is in small-pox. This is serious where the figures are presented for each disease separate- ly, neither combined nor compared with those of other diseases, (b) according to the pressure brought to bear upon physicians by the head of the respective divisions in the department of health. This invalidates a com- parison of one city with another: but within one city would be largely overcome by care on the part of the executive officials of the department to secure uniform- 93 Cases Reported as Index of Disease 24 Inaccuracies Due to Case Rates ft Comparison for Series of Years MAKING A MUNICIPAL BUDGET ity of practice in the different boroughs; (c) according to differences of policy in successive periods or adminis- trations : When the department of health begins a more vigorous campaign against any specific disease, an im- mediate result is likely to be an increased thoroughness on the part of physicians in reporting the cases. In tu- berculosis, for example, the number of cases reported to the department had been steadily rising every year for a decade or more, until in 1906 in Manhattan the new cases reported showed a decrease from those of 1905. On the other hand, a relaxation of pressure by the de- partment for any reason, would result in a falsely fav- orable showing. (2) Inaccuracies of diagnosis. In general, the de- partment of health accepts the diagnosis of the attend- ing physician who reports the case ; which diagnosis may prove to have been an error. Where the error is quite clear, the department commonly drops the report as "no case": the false diagnoses remaining are probably not numerous. Precisely to what extent the considerations mentioned would vitiate the use of the case rate as a measure of success, over a series of years (allowance being made, of course, for epidemics), it is impossible to assert. The difficulties are chiefly only possibilities, which might be largely eliminated or allowed for in practice. On the other hand, mortality figures could never, under the most favorable circumstances, be a closely accurate standard: they should be used only for lack of better. "From an economic point of view, sickness is more important than death; it is the amount and duration of sickness rather than the mortality that tell on the prosperity of the com- munity. * * * Mortality statistics necessarily ignore all that precedes the close of life." Since the use of the tables proposed does not involve an abandonment of the mortality standards, so far as they are of value, they would seem to afford a probable gain, with no possible loss. In any vital statistics, whether of prevalence or of mortality, conclusions must of course be based on the figures, not for a year or two, but for a series of years, the length of time varying in different instances. Five j» * f» « i * r '*. HEALTH BUDGET, NEW YORK CITY years is probably as short a time as will indicate, in most instances, any tendency that can be regarded as signifi- cant: while not less than fifteen or twenty years would be necessary to cover the periodical waves well recog- nized in contagious diseases. The figures for long periods belong in the report of the division of records, and are there given at present in respect to mortality, but not to cases reported. Short term statements, however, cover- ing perhaps five years, may well be given directly in connection with the statements of work done by the di- visions of contagious and communicable diseases, to be applied not as a strict standard of their success or failure, but as an approximate indication of the adequacy of the work done. Service Tables Recommended and Adopted The form in which the tables are presented in Exhibit 4 is that which would have been used in the annual report for 1906, if such a plan had been determined upon early enough to afford the necessary figures. In putting the plan into operation, it is understood that many of the figures for past years are not now available, and it is not suggested that any undue amount of effort be spent upon securing them. The records necessary to the form of report are now being instituted by the department and will in a few years provide all the facts called for by the tables. The Accountings System of the Department of Health In 1906 the principal records maintained by the de- partment of health were : appropriation and fund ledgers, order register and liability book, excess and rebate book, trial balance book, contract register (tabulation book) and segregation ledger. The Appropriation and Fund Ledgers were records kept with each appropriation and bond fund against which were entered all vouchers properly chargeable thereto. The entries were made after the vouchers had been finally approved. Each book was columnar in form, showing the amount of the voucher, the schedule number, the date, the name of the firm in whose favor 25 Short Term Statements of Limited Value Principal Accounting Records, 1907 Accounting Records Described MAKING A MUNICIPAL BUDGET the voucher was drawn, the division or bureau for which the goods or materials were ordered, the voucher num- ber, the date of the audit of the bill and the date that the voucher was sent to the comptroller. Instead of transferring unbalanced accounts of one year to a new ledger for the succeeding year, the ledgers themselves were kept open pending the final approval of vouchers chargeable to individual accounts. The Order Register and Liability Book was a record in which were entered all orders, whether contract or non-contract, sent out by chief clerks in response to requi- sitions (formal requests properly approved) from the several divisions and institutions desiring supplies. On receiving these requisitions, the supply clerk looked them over to ascertain whether the articles had been contracted for or not, and whether the goods requested should be obtained. When reviewed and initialed by the supply clerk, they were fon\^arded to the chief clerk, who, if approving them affixed his signature or initials. Orders were then prepared in original and five carbon copies. The original, with one copy, was sent to the firm from which the goods were ordered — the original to be re- tained and the copy to be delivered with the goods; a copy was sent to the division or institution requesting the goods ; a copy was sent to the inspector of supplies ; a copy was forwarded with the requisition; and a copy was held, to be transmitted with the bill and the voucher to the department of finance. The amount of the requi- sition was posted in the order register and liability book against the particular fund or appropriation drawn upon ; at the same time, entry was made of the requisition number, the date of the order, the division for which the goods were ordered, the firm from whom the articles were ordered, the estimated or contract cost of the goods, the actual cost of the goods, the date received, the date of audit, the number of vouchers and the date forwarded to the finance department. Because the estimated cost was often in excess of or less than the actual cost, the order register and liability book would need to be corrected after the final bill was received. Unless the difference between the actual cost and the estimated cost was noted, the order register .5 « -V HEALTH BUDGET, NEW YORK CITY and liability book would show too little or too much money available for a particular fund, and the appro- priation and fund ledger would indicate frequently that funds were available when funds were actually ex- hausted, or vice versa. All such excesses or rebates were entered in the Excess and Rebate Book, which is colum- nar in form, having a column for each month in the year and a page for each appropriation and fund. The Trial Balance Book was used as a means of de- termining the balance of appropriations. In it were recapitulated, in condensed form, the totals of charges against individual appropriations; the increases and re- ductions in estimates; the net estimated charges; the amount appropriated and the estimated balance of appro- priations subject to order. The Contract Register exhibited in tabulated form: contracts let for goods and materials to be delivered at stated intervals or upon requisition and order. This record was kept in two volumes, one for supplies, for which bills were rendered monthly, such as milk, meat, bread, fish, ice, mineral water, fruits and vegetables; the other for articles delivered upon requisition. In the case of the latter a pencil memorandum of requisitions made against contracts was carried until a bill was received when the pencil memorandum was changed to ink for permanent record. The Segregation Ledger was a statistical record to which audited vouchers were posted. In this ledger each class of expense had its own account showing against which appropriation or fund audited vouchers should be charged. The accounts in this segregation ledger were in turn summarized according to appropriations and funds Defects in the Accountingf System Employed by the Department of Health The defects in the accounting system above outlined may be said to be common to all of the department ac- counts of the city, namely, the controlled accounting records were those which pertained to appropriations and funds rather than to cost of operation. The pri- Accountins Records Describe I HEALTH BUDGET, NEW YORK CITY the work of the department is constantly developing records which reflect that work must also progressively develop. How adequate records, promptly and properly studied, lead to improvements in work, to changes of method and to corresponding changes of records and accounts, is illustrated by a "merger," now under consid- eration by the department, of district inspection of con- tagious diseases with medical inspection of schools. The discussion of the plan is based entirely on a care- ful study of the daily records employed during the later months of the school year ending June 30th, 1907. The health budget for 1907 recognized the distinction between the division of contagious diseases and the division of medical inspection of schools; each division has its own separate pay-roll; the school physician did not go into homes to inspect contagious diseases; there was, there- fore, no overlapping of work done, although there was an overlapping of territory traversed. To see whether time spent by inspectors on the street might be reduced, the following experiment was made in a small number of representative districts : The school inspector was asked to take charge of both the school work and the contagious disease work of his small district, going to the schools first, and making a house to house inspection after leaving the school. Only one physician worked in one territory ; this physician at- tended to all of the requirements of his district, included under the two headings, contagious diseases and school inspection. When the records of this plan were com- pared with the records of the prevailing plan (two men working in the same territory on different work) the following advantages stood out clearly in favor of merg- ing the t^vo functions in one man for a district fitted to the amount of work required : (i) Less time was lost on the street in going from inspection to inspection; (2) Consequently more hours were given to inspection ; (3) Responsibility for a district led to more efficient ser- vice in each division : (4) Concentration of responsibility in one man led principals, parents, family physicians, hospitals and dispensaries to co-operate more readily and more effectively, in securing necessary treatment for school children and in checking contagion. The depart- 31 Progress Means Changolice Maintenance Equipment Supplies CoBtingenciet % I I $ I I I 42 Exhibit j^Coniinued II BOROUGH ADMINISTRATION OP SANITA- TION AND PREVENTION OF CONTAGIOUS DISEASES— Continued Queens Salaries Office of assistant sanitary superintendent • S chief clerk s " " registrar of records. . . . 1 Division of inspections (a) Sanitary inspection, i. e., special in- spection, district inspection, mercantile house inspection, lod8:in8:-house inspec- tion (b) Pood, fruit, meat aud fish inspection . Division of conta&ious diseases Division of school medical inspection 1 s Sanitarv Dolice Maintenance Bauioment SuDolies Contingencies 1 s Richmond Sala&ies Office of assistant sanitary superintendent . . . 1 chief clerk 1 1 " registrar of records Division of inspections (a) Sanitary inspection, i. e., special in- spection, district inspection, mercantile house inspection, lodging-house inspec- tion s 1 ♦ (b) Food, fruit, meat and fish inspection . . Division of contagious diseases 1 Division of school medical inspection . . 1 1 1 Sanitary oolice Maintenance s Equipment 1 1 Supplies Contingencies 1 1 t1 i< I } Exhibit s — Continued III. DIVISION OF COMMUNICABLE DISEASES Salaries District inspection, medical inspection, tuberculosis nurses Manhattan The Bronx Brooklyn Queens Richmond Clinics for treatment of communicable pul- monary diseases, attending physicians and nurses (One appropriation for each borough) Diagnosis laboratory; bacteriologists; col- lection, preparation and examination of specimens — Manhattan only Maintenance Equipment Supplies Contingencies IV. LABORATORIES Research laboratory Vaccine " Chemical " Drug *• Maintenance Equipment Supplies Contingencies (Separate expense appropriations for each laboratory) V. HOSPITALS Riverside Salaries .... Maintenance . Equipment . . Supplies .... Contingencies $ $ S $ s i_ $ % % % % % % % [' 43 44 Exhibit s— Continued V. HOSPITALS— continued WlLLARD PAmKEX AlfX> RXCBPTIOK Salaries Maintenance Equipment *. Supplies Contmsenciet Kingston Avbnxtb Salaries Maintenance Equipment Supplies Contingencies .... Trachoma Salaries . . , Maintenance . Equipment . . Supplies . . . J < Exhibit J — Continued 4S ^.uuiiu^cucies % Otisville Salaries t % $ $ $ $ i Maintenance Equipment Supplies Continsrencies VI. MISCEI.LANEOUS (a) Removal of night soil (*) Support of private ambulance {c) Abatement of nuisances .... service . . . r (a) One appropriation for each borough id) One appropriation for Brooklyn and an appropriation for Queens {c) One appropriation for each borough Notes in Re Department of Health Budgfet for J908 SCHEDULE — Showing specifically the expenditures which will classi- fy under the general groupings respectively of ''Main- tenance," "Equipment," "Supplies" and "Contingen- cies" to wit: MAINTENANCE : Automobile Storage; Horseshoeing and Clipping; Livery; Care and Maintenance — Department Buildings; Repairs — Department Buildings; Repairs and Improvements to Grounds and Buildings only. EQUIPMENT : Furniture and Repairs to Furniture; Automobile Purchase and Repairs; Carriage Purchase and Repairs; Harness Purchase and Repairs; Horse Purchase and Hire; Stable Fixtures and Repairs; Disinfecting Fixtures and Repairs; Instruments and Apparatus ; Purchase of Cows. SUPPLIES : Books, Periodicals, etc. ; Miscellaneous Supplies ; Automobile Fuel and Supplies; Horse Feed; Stable Supplies; Standard Samples; Peppermint Oil and Uranine; Disinfectants; Disinfectors' Supplies ; Foods ; Drugs and Chemicals ; Drug- gists' Sundries; Fuel; Light; Clothing, Boots and Shoes; Dry Goods; Bedding; Notions; Crockery and House Fur- nishings; Freight and Express; Farmers' Supplies; Engi- neers' Supplies ; Carpenters', Gardeners', and Painters' Sup- plies ; Ice ; Blood ; Hire of Calves ; Milk for Vaccine Virus ; Needles, Boxes, etc.; Care and Maintenance and Medical Attendance of Horses; Purchase of small Animals; Feed for small Animals ; Boxes, Vials, and Syringes. CONTINGENCIES : Traveling Expenses; Carfares, Expressage, etc.; Automo- bile Hire ; Postage, etc. Traveling Expenses— Milk Inspec- tors; Disinfectors' Carfares. 46 47 I < Exhibit 4 Tabular forms devised by the Bureau of Municipal Research and adopted by the department of health for use in the latter's annual report to show the work done and results obtained in the various lines of activity maintained by the department ; with notes as to methods^ purposes and interpretation t % INDEX DIVISION OF INSPECTIONS GENERAL SANITARY INSPECTION Table i Nature of Complaints and Action Taken, 1906 Table 2 Complaints Disposed of within 30 and 60 Days, 1906 Table 3 Complaints Pending Dec. 31, 1906, and When Received Table 4 Premises Ordered Vacated, 1906 MILK INSPECTION Table 5 Comparative Summary of Infant Death Rate, Bacterial Content of Milk Samples, and City Inspection, 1902-1906 Table 6 Deaths and Death Rate of Children under i Year of Age from Diarrheal Diseases during the months of June, July, August, and September, 1902-1906 Table 7 Bacterial Content of Milk Samples, 1902-1906 Table 8 Milk Inspection within New York City, 1906 Table 9 Creamery Register, 1906 Table 10 Creamery Scores, All Creameries Registered, 1906 Table 11 Creamery Scores, Gain during 1906 Table 12 Dairy Register, 1906 Table 13 Dairy Scores, All Dairies Registered, 1906 Table 14 Dairy Scores, Gain during 1906 Table 15 Infectious Diseases Investigated, and Source Found in the Milk Supply 1902-1906 MEAT INSPECTION Table 16 Inspection and Condemnation of Meat, 1905-1906 Table 17 Pounds of Meat Condemned, 1906 INDEX TO EXHIBIT ^^Continued DIVISION OF INSPECTIONS— C^;z//;2w^ar INSPECTION OF FRUIT, FISH, AND OTHER FOODS Table i8 Inspection and Condemnation of Fruit, Fish, and Other Foods, 1905-1906 Table 19 Pounds of Fruit, Fish, and Other Foods Condemned, 1906 Table 20 Summary of Food, Samples Obtained, and Results of Analyses, 1906 INSPECTION OF MERCANTILE ESTABLISHMENTS Table 21 Employment Certificates, 1906 Table 22 Inspection of Mercantile Establishments, 1906 Table 23 Summary of Inspection of MercantUe Establishments, 1902-1906 LODGING HOUSE INSPECTION Table 24 Lodging House Inspections, 1905- 1906 SHORE INSPECTION Table 25 Shore Inspection, 1905-1906 COMPLAINTS, NOTICES, AND CIVIL AND CRIMINAL ACTIONS Table 26 Complaints and Notices : Division of Inspections, 1906 Table 27 Violations Forwarded to the Assistant Corporation Counsel for Civil Action, 1906 Table 28 Civil Actions Brought by the Assistant Corporation Counsel, 1906 Table 29 Criminal Actions for Violation of Sanitary Code, Charter, SUtutes, and Ordinances, 1906 Table 30 Criminal Actions in Magistrates' Courts, 1906 Table 31 Criminal Actions in Court of Special Sessions, 1906 INDEX TO EXHIBIT ^^Continued 49 m DIVISION OF CONTAGIOUS DISEASES DISTRICT MEDICAL INSPECTION Table 32 Prevalence of Contagious Diseases, 1902-1906 Table 33 Contagious Diseases: District Medical Inspection, 1906 Table 34 Contagious Diseases: District Nurses' Visits, 1906 MEDICAL INSPECTION OF SCHOOL CHILDREN Table 35 Prevalence of Contagious Diseases in School Children, 1902-1906 Table 36 Contagious Diseases Found in Schools by Inspectors and Nurses, 1906 Table 37 Medical Inspection of School Children for Contagious Diseases, 1906 Table 38 Prevalence of Communicable Eye and Skin Diseases in Schools in which there are Nurses, and Proportion of Exclusions therefor, 1902-1906 Table 39 Examination and Treatment of School Children for Non-contagious Physical Defects, 1906 Table 40 Medical Examination of School Children : Non-contagious Physical Defects Found and Treated, 1906 Table 41 Promotions among Children Treated and not Treated for Adenoids, 1906 Table 42 Nationality of School Children Found Defective, Needing Treatment, 1906 SUMMER CORPS Table 43 Summer Corps, 1906 Table 44 Summer Corps : Summary, 1902-1906 Table 45 Methods of Feeding of Children Registered by Summer Corps, 1906 Table 46 Methods of Feeding of Children Dying from Diarrheal Diseases and Investigated by Summer Corps, 1906 VACCINATION Table 47 Vaccinations in Schools, 1906 Table 48 Total Vaccinations by Department of Health, 1906 Table 49 Vaccinations by Department of Health, 1902- 1906 DISINFECTION Table 50 Disinfection of Premises, 1906 Table 51 Goods Disinfected or Destroyed, 1906 INSPECTION OF ANIMALS Table 52 Animal Inspection, 1906 DEPARTMENT STABLES Table 53 Department Stables, 1906 50 II Table 54 Table 55 Table 56 Table 57 Table 58 Table 59 Table 60 Table 61 Table 62 Table 63 Table 64 Table 65 Table 66 Table 67 INDEX TO EXHIBIT ^—Continued DIVISION OF COMMUNICABI.E DISEASES Tuberculosis : General Figures, 1897-1906 Deaths from Pulmonary Tuberculosis and Tubercular Meningitis, 0-15 years, 1897-1906 Tuberculosis Register : Living Cases, 1906 Summary of District Inspection of Tuberculosis, and of Treatment by the Department Clinics, 1906 Tuberculosis: District Inspection, 1906 Tuberculosis Clinics, 1906 Diphtheria : General Figures, 1897- 1906 Diphtheria : Injection, Intubation, and Immunization, 1906 Typhoid and Cerebro-Spinal Meningitis : General Figures, 1897- 1906 Typhoid Fever : General Figures and Inspection, 1906 Cerebro-Spinal Meningitis : General Figures and Inspection, 1906 Summary of Inspections, Visits, etc.. Division of Communicable Diseases, 1905-1906 Diagnosis Laboratory : Specimens Examined, and Results of Examination, 1906 Diagnosis Laboratory : Specimens Submitted for Examination, 1906 INDEX TO EXHIBIT ^—Continued 51 ,f^. HOSPITALS Table 68 Table 69 Table 70 Table 71 Table 72 Table 73 Table 74 Table 75 Table 76 Table 77 Table 78 Hospital Treatment of Contagious Diseases : Cases Treated, and Percentage of Total Cases Reported, 1902-1906 All Department of Health Hospitals : Patients during 1906 Reception Hospital : Patients during 1906 Willard Parker Hospital : Patients during 1906 Riverside Hospital : Patients during 1906 Kingston Avenue Hospital : Patients during 1906 Otisville Sanatorium : Patients during 1906 Reception Hospital : Service Rendered, 1906 Willard Parker Hospital : Service Rendered, 1906 Riverside Hospital : Service Rendered, 1906 Kingston Avenue Hospital : Service Rendered, 1906 Table 79 Table 80 Table 81 Table 82 Table 83 Table 84 Table 85 Table 86 Table 87 Table 88 Table 89 Table 90 Table 91 nOSVVTAJjS— Continued Otisville Sanatorium : Service Rendered, 1906 Reception Hospital : Case Fatality, 1906 Willard Parker Hospital : Case Fatality, 1906 Riverside Hospital : Case Fatality, 1906 Kingston Avenue Hospital : Case Fatality, 1906 Cases of Infection within Hospitals, 1906 Otisville Sanatorium : Patients Treated, and Condition when Discharged, 1906 Otisville Sanatorium : Duration of Patients' Stay, 1906 Otisville Sanatorium : Places to which Patients Discharged, 1906 Trachoma Hospital and Dispensaries : Number and Percentage of Apparent Cures, 1902-1906 Trachoma Hospital and Dispensaries : Special Annual Investigation Trachoma Hospital and Dispensaries : Treatment and Disposition of Cases, 1906 Trachoma Hospital and Dispensaries : Examinations, Diagnoses, and Treatments, 1906 LABORATORIES RESEARCH LABORATORY Table 92 Production of Antitoxic Serums and Diagnostic Toxins, 1905-1906 Table 93 Bacteriological Examination of Specimens, 1905-1906 Table 94 Pasteur Treatment, 1905- 1906 CHEMICAL LABORATORY Table 95 Specimens Submitted and Analyzed, 1905-1906 Table 96 Results of Analyses, 1906 Table 97 Number of Half Days of Attendance at Court, 1905-1906 VACCINE LABORATORY Table 98 Virus Produced, Tested, and Issued, 1905-1906 REMOVAL OF DEAD ANIMALS, OFFAL, AND NIGHT SOIL Table 99 Dead Animals, Offal, and Night Soil Ordered Removed, 1906 5* Object Activities Relation of Activities to Objects Exhibit 4— Continued GENERAL SANITARY INSPECTION The promotion of public health by the maintenance of general sanitary conditions. (a) Investigation by inspectors and sanitary police — (i) Of all citizens' complaints of unsanitary conditions. (2) To discover other unsanitary conditions not complained of by citizens. (b) Preventive and remedial measures for removing, in the manner prescribed by law, the unsani- tary conditions found illegally existing. The connection of general sanitary inspection with the public health, while entirely beyond question, is so ill-defined that seldom can measurable results rela- tive to the public health be shown to follow directly from the work done. It is, however, to be admitted on general principles that general sanitary inspection is necessary to render a city a healthful and decent place to live in. This assumption made, specific judgment may be passed as to the kinds of unsanitary conditions dealt with, the relative amount of effort spent on them (Table i), and the promptness of action (Tables 2-3). Table i Table i presents in classified form the complaints, coming under general sanitary inspection, which are received from citizens or filed by inspectors. The number of complaints given in the first column, in- cluding both those pending January i and those received and filed during the year, is exactly balanced by the five following columns. The table will show the nature of the complaints on which the bulk of the work in general sanitary inspection is required and the extent to which repeated inspection has to be resorted to in order to secure enforcement. Exhibit I— Continued 53 03 t N 9 s a •3 o 3 m a o e w n o 3 i o ^ < H' ^ w 7 2 o C^ ?r ffi £i — — — — ^ '=' ^ •*" fj w w sr •-» 0> D> B> W «* »♦ C* — <» f» ^ - 1 2 3 O 5- «• J» C o a> CL •"go- 2. 5 *^ 60* ?T -. ^ ST £S 3 2. 3 w n 3 c p. n n 3 M 2 = ? ^ iV- w w iT o o -• "I "1 5 n n - ■o -o . H. £. ° •1* "i" i' i' '^ O < 3 1 S. 1 o o 3 «» n o. CA n n a. ?r » —• n 3 u on 3 3 ' 5" a. 2. „ „ 3 S j» 2 » 3 -• 2. 3 CO 3 3 n ft rt r» 1 o< C ■cor) S K S 3 5. 2. '* 3 3 »^ OQ QtQ O « ^ 5 « 3 3 a. p (J o 2. 5.' '»*5 3 p 99 oq 3 • f? 2. £L •O 3 » 3* ^ p ~. >i tt ^ 3 V ^ •3 a 3 r» rt '^ ^ rt n rt SSSip ~. ^ p fli ta p -. - - 2 "^ 3 w (A Oq 3 3 r< I? ° < 3 «. ft a O 3 a ^ 3 o oq a P 3 oq O "I •3 P a an IE 3- ■^ •^ *• 2. " p 3 3 "S ? DO '^ ••• 33 1 S-' O, r> p 3^ 5* P 5. 5" 3 o =: ?. a ^ jr. 3 3 O 3 Oq P s a I o ?1 O > r* en > I— » > k: en o Number of items* o ft S > H - W ? o* I e m < Duplicates No cause for action t Referred to other depts. o n o ft p "tJ a a f% B n 3* > Returned for notices Pending Dec. 31,1906 ft A 8 Inspectors Sanitary police Total ft o* o n O c >q 3* SB :2: O Hj •" cn > > _ n ►—I o St > 54 Exhibit 4 — Continued r » Tables 2 and 3 Promptness in investigating complaints and in taking whatever action is necessary is an important indication of the efficiency of an in- spection force. While the promptness of inspection can be judged with exactness only by a continual examination of the daily or weekly office records, Tables 2 and 3 afford a sufficiently accurate basis on which to judge the work of the year as a whole. Table 4 Table 4 is in the same form as the corresponding table in the present annual report. f Exhibit 4 — Continued 55 Table 2 GENERAL SANITARY INSPECTION: COMPLAINTS DISPOSED OF WITHIN 30 AND 60 DAYS, 1906 New York Manhattan Bronx . . . , Brooklyn Queens . . . Richmond Complaints and ensuing: actions disposed of* in 1906 Disposed of* within 30 days No. Disposed of* within 60 days No. Not disposed of* within 60 , days No. In this table, the complaint and ensuing notice or legal action (if any) are all counted as parts of one operation. Complaints disposed of." therefore, in this table includes (1) citizens' complaints returned negative (no cause for action; the complaint beinfj without cause, or the cause being removed without issuance of notice): (2) all notices complied with, no matter whether oriein- ating with complaints of citizens or inspectors, and no matter whether before or after lejral action. The periods SO and 60 days are counted from the date of first receiving the complaint to the last date of its return as negative, or removal of cause of complaint (notices complied with) Table 3 GENERAL SANITARY INSPECTION: COMPLAINTS PENDING DEC 31, 1906, lAND WHEN RECEIVED New York Manhattan Bronx Brooklyn Queens Richmond No. *of total No. ar* all ^»..„«^^.4 — parts of one operation, which may be pending^t any on% of its^ft^S^s^ee n';,\eTndJr fable 2 " Table 4 PREMIISES ORDERED VACATED,* 1906 For city and each of five boroughs Number Date Location Cause Result •Section* 117« and 1299 of Chapter 466, Laws of 190L 56 Exhibit 4 ^Continued Object Activities Relation of Activities to Object MILK INSPECTION The promotion of the public health as affected by the milk supply. (a) Within the city: Inspection of milk in stores, on wagons, and to some extent at receiving stations, to see that it is unadulterated, sweet, and not above 50° Fahr. in temperature; and inspection of stores and wagons to see that sanitary con- ditions are maintained where milk is sold. (b) Chiefly outside the city: Inspection of creameries and dairies supply- ing milk to the city, to secure sanitary con- ditions. (c) Either inside or outside the city: Investigation of cases of infectious diseases suspected to have resulted from the contam- ination of the milk supply. It is agreed that there is an intimate connection between the deaths from diarrheal diseases of chil- dren under one year of age and the condition of the milk supply. To what extent other factors — such as the work of the summer corps, pasteurization, varia- tions in the ice supply, in the temperature, and hu- midity — enter in to modify the exactness of this rela- tion is of course open to debate; but it is safe to say that the relation is sufficiently close so that any thoroughgoing measure adopted by the department of health to protect the milk supply would be effec- tive to a greater or less degree in reducing the infant death rate from diarrheal diseases (Tables 5-6). f ♦ % • Eochibit 4 — Continued To reinforce this evidence, systematic bacteriological tests should be made. An analysis of several thousand samples each year, so taken as to distinguish pasteur- ized from unpasteurized milk, and so distributed as to be fairly typical of the total milk supply, would furnish a fair indication of the relative cleanliness of the milk supply from year to year (Tables 5 and 7). A study of results will enable the department to decide whether its "warning" line shall be drawn at 1,000,000 or 500,000, etc. Further evidence to the same point would be afford- ed by the reports showing the conditions in cream- eries and dairies (Tables 9-14). See Exhibit 9. In addition, there should be statements showing how strong the presumption is that a large proportion of the adulterated milk is discovered. For this pur- pose, statements for a single year convey little mean- ing. If, however, a statement covering several years shows, relative to the frequency of inspection (assum- ing the same efficiency throughout) an increase or decrease in the proportion of bad conditions to good, there is a basis for inference as to whether conditions generally are becoming better or worse (Table 5). The tracing of infectious diseases to their possible origin in the milk supply is virtually a kind of detec- tive work. It varies so from time to time that, while its results should be reported, they indicate little as to department vigilance (Table 15). 57 58 Exhibit i^Continued Table $ Table 5 is a summary for five years of facts given in more detail for the current year in Tables 6-8. It is intended to exhibit whatever corre- spondence there may be between the infant death rate and the cleanli- ness of milk supply (which reflects the work of creamery and dairy in- spection) and the results of city inspection. With a diminishing per- centage of samples containing over 1,000,000 bacteria per cubic centi- meter, a fall in the death rate might be expected. In the other columns, assuming the same degree of efficiency, if the frequency of inspection remains the same over several years, while the percentages of inspections finding adulteration or milk above 50** in- crease, the inference would be that conditions are growing worse, and that more inspection was needed : on the other hand, under the same con- ditions, a falling off in the percentage of adulterations found would argue an improvement. Table 6 The relation between the deaths from diarrheal diseases of children under one year of age and the condition of the milk supply is seen most clearly in the summer months, when the milk supply is at its worst and when children have in general least vital resistance to disease. Exhibit 4^Continued 59 Table 5 9 ! ♦♦ COMPARATIVE SUMMARY OF INFANT DEATH RATE, CITY INSPECTION AND BACTERIAL CONTENT, TEMPERATURE AND ADUL- TERATION OF MILK SAMPLES, 1902-1906 Infant death rate* t Bacterial content Inspections^ Temperature! Adulteration^ Deaths from di- arrheal diseases, June to Septem- ber, of children under 1 per 1,000 births during 12 mos.§ Percentage of milk samples containing over 1,000,000 bacteria per cu- bic centimeter Average num- ber inspections per permit per year Percentage of inspections finding milk above 50° Percentage of inspec- tions finding adulterations IJew York 1902. .. . 1903. .. . 1904. .. . 1905. .. . 1906. .. . Hach borough 1902. .. . 1903. .. . 1904. .. . 1905. . . . 1906. .. . • See Table 6 t See Table 7 X See Table 8 § The 12 months ending Sept. 30 Table 6 DEATHS AND DEATH RATE OF CHILDREN UNDER i YEAR OF AGE FROM DIARRHEAL DISEASES DURING THE MONTHS OF JUNE, JULY, AUGUST AND SEPTEMBER, 1902-1906 New York 1902 1903 1904 1905 1906 Bach borough 1902 1903 1904 1905 1906 * The 12 month • ending Sept. 30 June July Aug. Sept. Total 4 months Deaths, 4 mos., per 1,000 birtlis dorlnff IS moc* 6o Exhibit 4-^Coniinued Table 7 The bacterial content of milk is not suggested as a standard which can be enforced as to all milk sold in New York City. It is proposed however, as an important index by which the general condition of the milk supply can be judged from year to year. It can also, by the proper arrangement of the methods of taking the samples, be made a basis for comparing pasteurized and non-pasteurized milk, milk pasteurized in the city and in the country, and non-pasteurized milk at its different stages, 1. e., at receiving stations, at stores, and on wagons. Exhibit 4— Continued 61 Table 7 BACTERIAL CONTENT OF MILK SAMPLES, 1902 - 1906 Average daily milk supply (estimated) in gallons . Samples taken for bacterial examination January February March April May June July August September October November December 1902 1903 1904 1905 1906 NUMBER OF SAMPLES Year Whose bacterial content per cubic centimeter was found Spoiled Undar 100.000 Between 100.000 and 250,000 Between 250,000 and 500,000 Between 500,000 and 1,000,000 Over 1.000.000 Total 1902 1903 1904 1905 1906 PBRCEHTAOE OF 8AliFX.E8 Year Whose bacterial content per cubic centimeter was found spoiled Undar 100.000 Between 100,000 and 250,000 Between 250,000 and 500.000 Between 500.000 and 1,000,000 Over 1.000.000 Total 1902 1903 1904 1905 1906 100 100 100 100 100 I I i 62 Exhilni i^Continued Table 8 The bulk of city inspection is of milk in the possession of persons having permits to sell either in stores or on wagons. The field, there- fore, which city inspection has to cover is approximately indicated by the average number of permits in force; and the extent to which the field is covered is indicated by the average number of inspections per permit per year. The distinction between store and wagon is necessary because con- ditions vary so widely between the two classes of permits. One man may hold a large number of wagon permits ; whereas one man is not as likely to hold many store permits. This reason alone would account for a considerable difference in frequency of inspection : if a dealer maintains good conditions on one of his wagons, there is some presumption that he will on the rest; but in stores there is no such presumption. If it ap- peared either from the observation of the supervisory inspector or from Table 5 that more inspection was needed, the question would arise whether the added inspection should be of stores or of wagons. This would be answered by the records showing in each the proportion of in- spections finding adulterations. Exhibit 4 — Continued ^ Table 8 MILK INSPECTION WITHIN NEW YORK CITY, 1906 Permits issued durinsr 1906 * ' Permits revoked during 1906 For discontinuance of selling. . For violation of law Average permits in force in 1906 * t INSPECTION Regular inspections Inspections at receiving stations Total ATtrair* Inspeotions par perxnit p«r y«ar . . Specimens examined t Samples taken CONDITIONS FOUND Znspactioiui flndinff milk above BQo % of such di«coTerl«s to total inspections . Inspections finding* adulteration X Warning: ffiven g Prosecuted § i of adulterations found to inspections . . . Rooms connected contrary to sanitary code .... Ice box badly drained Ice box unclean Store unclean Utensils unclean Milk not properly cooled Infectious disease Persons found selling: without permit ACTION TAKEN DESTRUCTION OF MILK Itots of milk destroyed for bein^f over 60° Quarts so destroyed Lots of milk destroyed for being sour 2uarts so destroyed ots of milk destroyed for beinir otherwise adulterated Quarts so destroyed Total quarts destroyed ....•* NOTICES ISSUED || To drain and clean ice box To clean store CRIMINAL ACTIONS BEGUN H For selling adulterated milk ; . . For selling: without permit For interference with inspector Total New York Stores Wafons Each boroug:h Stores Waeons • Average in force on the first of each month t Several specimens may be examined at a single inspection X Samples taken and analyzed .. } y^^ technical definition of adulteration is found in Section 53 of the Sanitary Code, the chief items bein» containing: less than 12 per centum of milk solids" and "containing less than 3 percentum S f^s"' ?2*'i?^-r!™"* 5 distinction is made between samples whose milk solids iri fouSd betwSS l^and 11 5*-' 12#-n.4# are made occasions for warning only, under 11.4« for prosecution "ciwccn i^» ana im%. I For action upon notices, see Table 26 t See Table 29 la \ih Exhilni 4-^Continued Tables g-ii The department of health has installed \vhat is in effect a register of the creameries sending milk to New York City, together with a score record of their condition at the last inspection. Table 9 gives the number of creameries enrolled, together with the number inspected, and the frequency of inspection. Table 10 shows the number and percentage of creameries whose condition is classed at the beginning and at the end of the year as good (between 75% and 100%), fair (between 50% and 75%), and poor (under 50%). The year's work should bring about a higher percentage of those classed as good or fair. The average score of all creameries enrolled should also rise. Table 11 is designed to show wherein the improvement consists. The department is in a position to report improvement during the year, of course, only in those creameries which it has inspected more than once. For these creameries, therefore, the gain is analyzed accord- ing to the subdivisions of the score card used. Tables 12-14 Tables 12-14 are, for dairies, the same as 9-1 1 for creameries. Exhibit 4— Continued g Table p CREAMERY REGISTER, 1906 Enrolled Jan. l, 1906 New creameries scored during 1906 Total Creameries dropped during: 1906 enrolled Dec. 31, 1906 ToUl . . , Creameries inspected at least once V«ro«nt»ff« of total iiLsp«ot«d at least onc« ............ Number of inspections ▲T«rair« ln»p«ctioii« ptr 7«ar per place l&speoted. ......./..'..... Table lo CREAMERY SCORES : ALL CREAMERIES REGISTERED, 1906 Scores at last inspection Number resistered Peroentage of total Jan. 1. 1906 Dec. 31. 1906 Jan. 1, 1906 Deo. 31, 1906 Between 75 and lOOit 50 and Ibi Below 50it Total 100 100 ATera^e score at last iaspeetlon, Jan. I, 1906 . " " " " Dec. 31, 1906 u Table n CREAMERY SCORES : GAIN DURING 1906 Creameries inspected more than once in 1906 Perfect score Single cream- ery ToUl Location and surroundinsrs Rooms: arrangement and ventilation Walls, ceiliuKs, floors Drains and drainage Utensils and apparatus Water or ice supply, tanks, etc. . . . Methods of handling milk •Cleealioest of attendants 100 8 16 16 12 13 22 7 6 Agrgre- srate At first inspection Anrre- gate ofper< feet seore , At last inspection Aggrre- gate ofper- fSet seore Gain Aggre- gate t of ffaia ^ Exhibit ^-Continued Table 12 DAIRY REGISTER, 1906 Enrolled Jan. 1, 1906 New dairies scored during 1906 . . ^ Total ..././.,, ,.,..,, Dairies dropped during 1906 enrolled Dec. 31, 1906 Toul ..!.!!.!!!!!!!.!! Dairies inspected at least once P«ro«ntaff« of total ln8p«ot«d at l«Mt one* Number of inspections ▲▼•rsff* inspttotloiui p«r j«ar p«r plao« inspecttd Table 13 DAIRY SCORES : ALL DAIRIES REGISTERED, 1906 Scores at last inspection Between 75 and lOOit 50 and 75« Below 50it ToUl Number registered Jan. 1, 1906 Dec. 31. 1906 y«re«ataff« of total Jaa. 1, 1906 AT«rar« Moro at last iaapootioap Jan. 1, 1»0« " " " " Doe. 81, 1906 I>«o. 81, 1808 100 •f Ta:ble 14 DAIRY SCORES: GAIN DURING 1906 Dairies inspected more than once in 1906 Total Condition of Stables Cow yard Cows Milkers and milking Utensils Milk house Water supply .... Perfect score Single dairy Aggre- gate 100 40 3 21 13 6 7 10 100 At first inspection Aggre- gate ofpor- foot At last inspection Aggre- gate ofpor- foot ■ooro Gain Aggre- gate «of Exhibit 4— Continued Table 75 INFECTIOUS DISEASES INVESTIGATED AND SOURCE FOUND IN THE MILK SUPPLY, 1902-1906 TYPHOID Suspected cases referred for investigation . . . . Cases of infection traced to milk supply SCARLET FEVER Suspected cases referred for investigation . . . . Cases of infection traced to milk supply 6S Exhibit 4 — Continued Object Activities Relation of Activities to Object MEAT INSPECTION To promote the public health by seeing that the meat slaughtered or sold in the city is fit for con- sumption as food. Inspection of butcher shops, stores, packing houses, ice-houses, stands*, vessels*, markets, railroad depots, stock yards, slaughter houses, commission houses, fat houses, and licensed venders;* and condemnation of meat found to be unfit. The relation of meat inspection to the public health is not so definite that its adequacy can be measured in health terms. It cannot be stated, even approximately, to what extent the public health is improved by meat inspection. It is admitted on general principles, how- ever, that inspection of the food supply is necessary. This assumption made, the question is one of covering the supply as thoroughly as possible. Table i6 , Table i6 shows the kinds of place inspected, the average frequency of inspection of each, together with the number of condemnations and pounds of meat condemned in each. The number of condemnations is given separately from the amount condemned, in order to indicate more accurately the amount of work involved. It would take more inspections, for example, to condemn a given amount of meat in butcher shops than in packing houses. Conditions vary from year to year to such a degree that comparison with more than one preceding year would probably be of little value. * The number of establishmetits of the kinds indicated (*) is so variable that the averase number of inspections of each per year would mean little. For the rest, however, such a figure would afford « basis for comparing successive years. Exhibit 4 — Continued 69 a- > : n B- (* o n o S ■* «» "i -• "'^ S-S3 E n f* o rt sr 9 n s-gs: c a. O -I -• 2 V r» •o --^ c »'-' •» — £ < 2e: ^l n M n — < a* n < n *» £ •1 *» m a c I (* n **• o a r* *ri n w t/i 93 ^ ^ ui w ^ •■ 3 - O *• ** 3 Brgoq K f' ^ '^ S o 5. =r IS •*• "1 £. *• ^^ O M s* C * n a o. n •1 ►-• hfl M tt S S o c O 3 " »» C n 1 CO 3 ^ o c w n sr o e (A w 3* O •O 10 o 3* O S 3* w OS. sr 2.— w)03*'r» o» (o u) 2 s» s^ * < » 2 D. rt •=> 3* 3 O. -1 w * O M s (* M W rt C0 r» w IB 3* O c (A o 2 PI O r» — B r» o » "••►1 S3 < 2 " 2 «5 09 rt O " ^1 SB BS§ »< n o B V l> p M o 5 o > O o o 5J > H o O t I M O o CuO i» e BB 2. Ov 70 Exhibit 4— Continued Exhibit 4^ Continued n o Table 1/ Table 17 is simply a subdivision of column 5 of Table 16, to show what kinds of meat are condemned in the different places. B «■ < s 3 r^ fg t% ft f* ^ ' U*^ o B B* O B* e a M a a u a Beef Veal Sheep Hoes Assorted meats 2 O Poultry Game ToUl O d o O O 3 i Beef Veal Sheep Hosts Assorted meats Poultry « n 3* Bk < O* O •t o s B* Game ToUl 72 II: ill Object Activities Relation of Activities to Objects Exhibit 4— Continued INSPECTION OF FRUIT, FISH, AND OTHER FOODS To promote the public health by seeing that the fruit, vegetables, fish, and other foods (chiefly canned goods, confectionery, groceries, and eggs) that are sold are in fit condition to serve as food. (a) Inspection of commission houses, retail stores, licensed venders, vessels and wharves, railroad depots, stands, markets, ice houses, and push carts; and condemnation of foods found to be unfit. (b) Gathering of samples of confectionery, canned goods, etc., for analysis ; and initiating action against dealers whose foods are found adulterated. (c) In connection with both (a) and (b), the san- itary inspection of the places where foods are sold or manufactured. The process of marketing perishable foods is so subject to fluctuations that no definite formulation can be made of the conditions under which the work is carried on. A commission house may be selling fruit one week and not the next; cargoes arrive ir- regularly; and the methods of handling are such that the number of inspections per place cannot be taken as a fair standard of judgment. All that is suggested for an annual report, therefore, is the statement of inspections, condemnations, and amount condemned in each kind of place.* Table i8 In Table i8, as in Table i6, a distinction is made between con- demnations and amount condemned, in order to show more accurately the amount of work involved. •S«« paje 19 Exhibit 4— Continued 73 Table i8 INSPECTION AND CONDEMNATION OF FRUIT, FISH AND OTHER FOODS, 1905-1906* NEW YORK Commission houses Retail stores , Licensed venders . . . Vessels and wharves R. R. depots Stands Markets Ice houses Push carts Total Each of five boroughs Commission houses . Retail stores Licensed venders ... Vessels and wharves , R. R. depots , Stands Markets , Ice bouses Push carts Total •The process of marketing perishable foods is so subject to fluctuations that no more definite^ formulation can be made than that based on inspections 74 Exhibii 4^Continugd Table ig Table 19 is simply a subdivision of column 3 of the preceding table, to show what kinds of food are condemned in the different places inspected. Table 20 The specimens whose analyses arc reported in Table 20 are used for the most part as the basis for legal action against the dealer from whom they were obtained. The approximate extent to which they are so used can be seen by comparing Table 20 with the criminal actions initiated by this branch of food inspection, as given in Table 28. H Exhibii 4 — Continued 75 £. 3* 3. o o 5 c Sj CO 50 o 5 S w • 2 •♦ ST • 2* " 2 » 1 5 <, S ff * 3 2 < o o B a »«• ce CD O B 3* O c M Fruit 5! < Vegetables Canned goods Confectionery Groceries Ekks Pish Miscellaneous Total Fruit « » n tr ft e 01 Vegetables Canned goods Confectionery Groceries Eggs Pish Miscellaneous Total O a O Jd d CO > o O o !2S w 1 s 76 Exhibit 4— Continued ^ < ;;? on •i C 73 C/5 (0 1 n o. 3 c Q. (A <• 3 2 « » S >< O vh s 5 a 1/1 •1 < < o 3' 1 fii o (A o 3 "■*» n n o' 3 n n o 3 O. n 3 w f» a. O o •o 3 c n n 3 3 3 3 fi n Qu a » u 1 ri 3 c n (t w a* fi> 3 X* O ft SB o B »< O B O K O s B 3 ^ CD 3 il (B a B o 3 B ' O B M ;s§ o s B m c B B c O C/) > r m o w > w > o W (/) c r O > > w en 2- o.'i^ Exhibit 4— 'Continued 77 MERCANTILE ESTABLISHMENTS To regulate certain conditions under which women and children may work in mercantile establishments. While there is an ultimate health object, it is too re- mote to be of service in measuring the results of service rendered. (a) The issuance of employment certificates to children between 14 and 16 years of age. (b) The inspection of mercantile establishments to enforce the law relating to the employment of women and children therein. Assuming efficiency of supervision to secure thor- ough inspection, successful inspection of mercantile establishments should result in few violations of law existing, and therefore few violations found. Since a large number of establishments may need inspecting only once or twice a year, while others may need al- most constant watching, the extent to which this is •done would appear only from the daily or weekly office records. The most significant facts that can be brought out in an annual report are perhaps the total number of mercantile establishments inspected at all during the year, the number in which violations of law were found, and the average frequency with which these latter were inspected during the year (Table Object Activities Relation of Activities to Object L 78 Exhibit 4 — Continued 7 able 21 EMPLOYMENT CERTIFICATES, 1906 Applications for employment certificates* Granted Refused By reason of insufficient education By reason of insufficient tuition By reason of insufficient evidence as to birth By reason of physical incapacity By reason of being under age New York Certificates in force January 1, 1906.... Certificates granted during 1906 Certificates expiring during 1906 Certificates in force December 81, 1906. Man- hattan Bronx Brook- lyn Duplicate certificates issued. Queens Rich- mond Exhibit 4— 'Continued 79 Table 23 •Children applying and found over age are considered as not having applied Table 22 INSPECTION OF MERCANTILE ESTABLISHMENTS.* 1906 INSPECTION Mercantile establishments inspected in 1906.... Mercantile establishments in which violations of law were found Total inspections of mercantile establishments. Inspections of mercantile establishments in which violations of law were found AT«rac« iiuip«otlon8 p«r 7«ar p«r •stab- ll8]im«iit w]&«r« Tlolations of law w«x« found VIOLATIONS Violations of law found Children employed without certificates M(Ae Female Basement occupied No seats for females No separate toilets for females No register kept Work after 7 r. u Work more than 9 hours a day Work more than 54 hours in a week Law not posted New York Man- hattan Bronx Brook- Ism Queens Rich mond SUMMARY OF INSPECTION OF MERCANTILE ESTABLISHMENTS 1902-1906 * For complaints and notices, see Table* 26 New York 1902. . 1903. . 1904 . . 1905. . 1906. . Manhattan 1902. . 1903. . 1904 . . 1905. . 1906. . Bronx 1902. . 1903. . 1904. . 1905. . 1906. . Brooklyn 1902. . 1903. . 1904. . 1905. . 1906. . Queens 1902. . 1903. . 1904. . 1905. . 1906. . Richmond 1902. . 1903. . 1904. . 1905. . 1906. . Number in which violations found Inspections of places where violations found Average inspections per place per year Number of violations Children without certificates Other violations ToUI So Object Acti\ ities Relation of Activities to Object Object Activities Relation of Activities to Object Exhibit 4—Coniinued LODGING HOUSE INSPECTION To promote the public health by maintaining sani- tary conditions in licensed lodging houses. Inspection of licensed lodging houses. As in several other lines of inspection maintained by the department of health, it is impossible to in- dicate any definite health results following from the work done. The absence of epidemics originating in lodging houses is hardly a measurable piece of evi- dence. As for the activities themselves, they are so miscellaneous (cf. pp. 112-113, Report of 1904) that re- porting them in detail would be of little value. All that is suggested, therefore, is the number of places inspected, the number of inspections made, and the average number per place per year; for the rest, it must be left to the supervising officer to see that what is necessary is done. SHORE INSPECTION To keep shores clear of dead animals and offensive refuse. It is carried on only in Brooklyn and Rich- mond. Inspection of shores. No definite health results can be ascribed to shore inspection. Even the inspection itself cannot be formulated with sufficient definiteness to be of value. A purely formal report is given of the number of in- spections and of the number of objects removed from the shore. Exhibit 4 — Continued 81 Tabu 24 LODGING HOUSE INSPECTION, 1905.1906 New York. Manhattan Bronx . . . Brooklyn . Queens . . . Richmond . Permits Inspections Average inspections per lodsrins: house per year 1906 1905 Table 2s SHORE INSPECTION, 1905-1906 Brooklyn Richmond 1905 1906 1905 1906 Inspections 1 Pound and disposed of Human bodies Carcases of animals Dogs Cats • Rats Goats Sheep Hogs Catves :...... Horses Fowls Fish Bedding, pieces Clothing, pieces Meats, pieces Offal, pieces Mattresses, number u. 82 Exhilnt 4^Cl>ntinued COMPLAINTS AND NOTICES Table 26 Instead of taking space for a statement of complaints, arrests, etc., in the report on each line of inspection, it has seemed better to make a single statement for all. Table 26 presents, for each line of inspection, the complaints received from citizens, those filed by inspectors, the va- rious dispositions made, and action (if any) taken, together with the cases pending in different stages at the close of the year. Exhibit 4— Continued 83 ♦♦-♦•• •• 3 030 -. o »♦ a o g. " a> S »> H n n (0 >*« fit r» o 3 M S R 3 S § o sis § £*S « 3 o o « — •^ § 8 ^. 8 o- — c »Q 2 c 3 3 "O & a n 55 3 2 «' 3 » 2 e» 3 3 n Q. **• ^ 2 5"^ S 3 Q. S —CO o «v O •< ■ n (B O. n a — O 3 3 s o ^•3£ 3 S's- 9 •1 6 3 oO 3 2 3 (t W 1 ;jj 2J Z 2 o o s <-» •« 2; o o •» n ft C* -if 3 sr: "" a* 0' 3 M • Br « y:. e 2. »• eo "-« ?♦ -r s 9* i' s n » rt 5. rt 2 f» — w S » ft S o o o H ^ -• -• 2 2 2 PI (A 2 e 3 n a. a. 3 3 3 «J C 1 "^ « vd O 0« M o 0\ Q r* f^ r^ 3 0' o' 0' » 3 3 3 ■•-»• ++ ♦+ 2. • • • 1* • • . cr ... 2 o 9 9 p* 5;* a 3 3 g • SL 8 t ?^ ^ 3 3 O f?' r> «• 0-3 ® .g H P c » 9^ S 2 «» » ^ ^«» 2 3 »> 3 o o < 5_ » -»■ 3 o a n n a on ^" 2 N-9 n "O 3 ;r w 11. - 3 f> o 9 -o •2.3 2. Q. 3 5' 10 8Q •1 n i_H n fi} n 3 ••• s < C 1 " C 5? o " o 9 ■o r 3> JT o. o. c 3. 3 09 n o > H o 3 0Q O 0\ o < 2. o e I S B O f General sanitary inspection Milk Meat Fruit, fish, and other foods Mercantile Total 525 o General sanitary inspection Milk Meat Fruit, fish, and other foods Mercantile ToUl m n tf o < 3 c •q n o > I— t H en > O o H »-^ o w en t— • Ov d t— • < »— • m O O en W O H i-« O rz: en "* • Exhibit 4— Continued CIVIL AND CRIMINAL ACTIONS Table 2j-ji Persistent violations of law may be forwarded to the assistant corporation counsel who thereupon issues a notification of intention to commence civil action ; if the compliance is secured by this notifica- tion alone, suit is not brought ; continued non-compliance results in suit. Actions are discontinued, however, at almost any stage if compliance is obtained. Table 27 gives the total violations handled by the assistant cor- poration counsel for civil action, Table 28 the total suits actually brought, together with their disposition. There is no exact relation be- tween the number of violations on which suit is begun and the number of suits begun, for the reason that several suits may be, under various circumstances, brought on one violation. The number of actions arriving at the point of judgment is too small to warrant their classification according to the violations of the law with which they originated. Not so, however, with the criminal actions. Out of 2724 cases in 1905, 2321 resulted in conviction in the same year, — a sufficiently large number to justify classification, as in Table 2^, Upon a judgment being vacated it becomes an action pending, and is then, after the order is reported complied with, counted as a civil action discontinued. Table 29 Table 29 is a modification of a table now given in the annual re- ports of the department (see page 152, Report of 1904). The new form is designed to show for each line of inspection and for each borough the criminal actions begun, whether by arrests or summons, and the results of the actions. It is intended to include all crim- inal actions initiated by the department, whether in magistrates' courts or in special sessions. The subdivision between these is made in Tables 30-31. Exhibit 4 — Continued Table 27 VIOLATIONS FORWARDED TO THE ASSISTANT CORPORATION COUNSEL FOR CIVIL ACTION, 1906 85 VIOLATIONS RECEIVED Violations pending January i, 1906 Violations received and notices sent Total violations during 1906 DISPOSITION Complied with before suit Suit begun Pending (without suit) December 81, 1908 and awaiting instruction by department of health Total violations during 1906 New Man- York hattan Bronx Brook- lyn Queens Rich- mond Table 28 CIVIL ACTIONS BROUGHT BY THE ASSISTANT CORPORATION COUNSEL, 1906 ACTIONS BEGUN Civil actions pending January 1, 1906 Civil actions begun in 1906 to recover penalties on violations Other civil tctions begun Judgments vacated* Total suits during 1906 DISPOSITION Discontinued; compliance secured. Judgment recovered Pending December 31, 1906 Total suits during 1906 Amount of costs, penalties and judgments col- lected in civil actions and paid to secretary of board of health Amount of claims collected before and after suit for antitoxin and virus and paid to secretary of board New York Man- hattan Bronx Brook- Ijm Queens Rich- mond •Upon a judgment being vacated it becomes an action pending, and is then, after the order it reported complied with, counted as a civil action discontinued !l 86 Exhibit 4^Continued 8 1 o B o o B O B CA n o* B B o 5" B B ca •O rt n o B on en H. 3 5S o a n «. S. a. o Si. 3 B O B m B n m B n w B* 3 ft Bi m B* B a o sr 1% B :; a » O 2 R) 3 3 cn gt 5 J? o b: a a f> r» "I » a U n C3« IB M* ^ M- M a' » a a c a> 1% B 3 7 O B rt a n ft o o 9 K t* o 5: - 5 m a rt ft m B a I 5* f» »*• o B O cr s rt o a B_ r3 rt o a i' ! Warrant or summons Presence of patrolman Total Sentence suspended Discharsed Pending Dec. 31 Total Amount of Pines 2 Warrant or Summons Presence of patrolman Total Sentence suspended Discharged Pending Dec. 31 ToUl Amount of fines H m rt B* at 6 B* n 5 m i I S I g o > >< n o o « > H « CO > G > o o d ? aj o Exhibit 4— Continued 87 Table 30 CRIMINAL ACTIONS IN MAGISTRATES' COURTS, 1906 CASES Pending January i, 1906, in Magistrates* Courts. New cases during 1906 in Magistrates' Courts.. Total cases DISPOSITION Held for Special Sessions Discharged Fined Sentence suspended Appealed Fending December 31, 1906 Total cases Amount of fines New York Man- hattan Bronx Brook- lyn Queens Rich- mond Table 31 CRIMINAL ACTIONS IN COURT OF SPECIAL SESSIONS, 1906 CASES Pending January i, 1906 Transferred from Magistrates' Courts. New cases during 1906 Total cases DISPOSITION Discharged Fined Sentence suspended Appealed Pending December 81, 1006. Total cases New Man- York hattan Amount of fines. Bronx Brook- 13m Queens Rich- mond Object Activities I Relation of Activities to Object ExhiHi 4^Continued CONTAGIOUS DISEASES: DISTRICT f MEDICAI. INSPECTION To diminish the prevalence of contagious diseases. (a) Inspection of cases reported by attending phy- sicians and school inspectors and through complaints. (b) Either quarantining or sending to a hospital the cases found. (c) Ordering of disinfection. Over a series of years there should be a decreasing prevalence (case rate)* of contagious diseases (Table 32), though the decrease could not correspond with exactness to the amount of work done in district med- ical inspection alone, since other lines of work con- tribute to the same result, such as disinfection, school inspection and hospital treatment. District medical inspection, however, is the main factor. It is recog- nized, of course, that allowance must be made for the recurring waves of epidemic or partial epidemic; yet in these, the successive waves may be expected to show a gradual decline. To assist in the work of inspection of contagious diseases, there are in Manhattan alone a few (at pres- ent, two) district nurses. Their work is so varied, so largely educative, so closely allied to that of district inspection, as to make it impracticable to attempt an entirely independent statement. Table 34 seems as much as is now feasible. * See iMkget 22, 23 and 24 Exhibit 4'~Continu^d n »-• l^ I— H- H^ 5 - T » tt ^-* ^^ ^^ ^-^ ^^ fi K liiiil. giiiii iii§«s M ^^ t-^ t-^ h^ t-^ t^ ^.tfl^^^^.1^^ t a w 8 c »Q • • ■ • • M 1 Wi * Oi ro*^ ft < f* "I ' ►"* ►^ ?5* . . ft Sat o B o e B B90 B » B B • O B M U "< 2 B O K O B n n B ai B90 •0 »t o s g" "I o B B f* m •1 f* o 2. - M I M 89 > % » o n o > O §^ CO > CO M CO ? ^ Il 90 Exhibit 4— Continued Table 33 Table 33 gives, for each disease, the number of cases reported and their disposition, the frequency of inspection of cases quarantined at home, the number of other inspections, and the number of disinfections of premises and of goods ordered. The most significant figure is, perhaps, that of the average number of visits per case quarantined at home for its entire course, from which an approximate idea may be obtained of the thoroughness of the sur- veillance which the department is able to maintain. The number and proportion of cases treated in the hospitals of the department is given in Table 68. The number of cases there given as treated will somewhat exceed the number given in this table as re- moved to hospitals, on account of the cases that simply "walk in." The special inspections of institutions for orphans, destitute or vagrant children, or juvenile delinquents, provided for in Chapter 561 Laws of 1893,. as amended by Section 2, Chapter 667, Laws of 1900, are given separately. , . ..jii III ill Exhibit 4— Continued ^ » o 3 •-•9* O C 3 "* ►^ff.O — O 3 •< O ** erg pi 1^ •» B^ g ' 2:2 33 w (* <0>. waSo o « ^a 9 e n so ^ '♦•If*! o 2 "-• Sa> •< o c/i 0.0. 3 3 o o (A (« »♦ »♦ 3 3 w w « ff.Q O 3 ►H » 2 n " I 2 V * lu n ^ i-j H?2!r»^oo5; 9:2. V o q 2 r» 3 < l±n> I 1?H a S o.a.3 2 ^ 3* O 3 Oc 3 3 S » rt 3 o." 2.0 u 3 3*3 »»0 M « O Ok .2.2 » p3S 3" 3-g-i S.S3 Jto» 2 5-r-3 3 * o o > (A w CO n o <» w ^ 09 .3 3 n M MO o- A- ^ § A. •i «» 3 ST o. «.J 5* e (* a n t 4* sr i o M OD 7 t Diphtheria Scarlet fever Measles Small-pox Chicken-pox German measles Non-contagious Total 5S o Diphtheria Scarlet fever Measles Small-pox Chicken-pox German measles Non-contagious Total n St at < 3 s n 3* 91 o o H > cn o a cn > c/i W cn cn H ?3 m o n > r 2: cn W o H o a: I 92 Objects Activities Relation of Activities to Object Exhibit 4^Continued MEDICAL INSPECTION OF SCHOOLS (a) To diminish the prevalence of contagious diseases among school children, and thereby indi- rectly among children under school age. (b) To discover in school children non-contagious physical defects which affect their power to do school work, and to urge upon parents the necessity of treat- ment. (a) Systematic inspection of school children by physicians and nurses. Cases of general communi- cable diseases are excluded from school and referred to the district medical inspection force for proper iso- lation; in cases of communicable diseases of eye and skin, treatment is either given in school by the school nurses or secured through their urging it upon parents. In schools where there are no nurses, the more aggra- vated cases of eye and skin diseases and those per- sistently showing no evidence of treatment are ex- cluded by the medical inspector. (b) Physical examination of children and notifica- tion of parents when treatment is needed. In so far as the activities under (a) are successful,, there should be, over a series of years, a decreasing prevalence of contagious diseases among children of school age. In so far as the activities under (b) are successful^ there should be ultimately a smaller proportion of children who are backward in their school work. But at present, records are not available which would show definitely and on a large scale the results of treatment for physical defects: such records, to avoid duplication, might best be maintained by the depart- ments of education and health jointly. It is feasible^ however, for the department of health to show in certain selected schools the results of treatment for certain specified defects (Table 41) and to show in general how far it is able to induce parents to secure treatment for their children (Tables 39-40)- Exhibit 4 — Continued 93 SCHOOL NURSES Objects The work of the inspectors and the nurses is so intimately related that on the whole it is better to present a combined report. The fol- lowing considerations, however, apply to the nurses alone: (a) To cause a marked decrease in the prevalence among school children of communicable diseases of the eye and skin. (b) To reduce to a minimum the number of ex- clusions of children from school on account of such diseases. "Routine" inspection to discover all cases of com- municable eye and skin diseases (except trachoma, for which the inspectors examine) ; treatment according to directions by medical inspectors, or securing of treatment through instructions in school or visits at homes. Cases of pediculosis, however, are completely in the hands of the nurses. Success in achieving (a) should be seen in a de- creasing prevalence of communicable diseases of eye and skin among the children of the schools in which the nurses work. In so far as (b) is achieved, a low percentage should be reached of exclusions for these diseases (Table 38). The comparisons suggested, it will be observed, are only of year with year in the schools where there are nurses, not of these schools with others where there are no nurses. Activities Relation of Activities to Objects 94 Exhibit 4 — Continued Table 34 CONTAGIOUS DISEASES : DISTRICT NURSES' VISITS, 1904-1906 Diphtheria 1904 1905 1906 Scarlet fever 1904 1905 1906 Measles 1904 1905 1906 Manhattan Cnone in other boroughs thus far) Cases visited 1 Visits Average visits per case Exhibit ^—Continued 95 Table 35 PREVALENCE OF CONTAGIOUS DISEASES IN SCHOOL CHILDREN Case rate by years and boroughs, 1902-1906 General communicable diseases* Number Found by inspectors In school Among absentees Reported by attending physicians Total New York 1902. 1903. 1904 . 1905. 1906. Manhattan 1902 . 1903. 1904 . 1905. 1906. Bronx 1902. 1903. 1904 . 1905. 1906. Brooklyn 1902. 1903. 1904. 1905. 1906. Queens 1902. 1903. 1904 . 1905. 1906. Richmond 1902. 1903. 1904 . 1905. 1906. Vumber per 1,000 re{ristered iu schools iiuspectecL Communicable d iseases of eye and skin t Number found by inspectors and nurses V n mber per 1,000 registered in schools inspected ♦Small-pox, diphtheria, scarlet fever, measles, chicken-pox, mumps, and whoopingTcongh; excluded when found t Trachoma and other contagious eye diseases, ringworm, impetigo, scabies, favus, and pedicti* losis; excluded only for persistent non-treatment Exhibit 4^Continued Exhibit 4^Continued 97 Table 36 CONTAGIOUS DISEASES FOUND IN SCHOOLS BY INSPECTORS AND NURSES: 1906 Number and disposition of cases General communicable diseases New York Cases found in schoolst ' Cases excluded from school Cases treated in school! ■ Cases instructed in school, or evidence of treatment furnishedg Number of treatments! Number of instructions^ Manhattan Cases found in schoolst Cases excluded from school Cases treated in schooU Cases instructed in school, or evidence of treatment furnished^ . . - Number of treatments! Number of instructions! Bronx Cases found in schoolst Cases excluded from school Cases treated in school! Cases instructed in school, or evidence of treatment furnished! Number of treatments! Number of instructions! Brooklyn Cases found in schoolst Cases excluded from school Cases treated in school! Cases instructed in school, or evidence of treatment furnished! Number of treatments! . '. Number of instructions! Queens Cases found in schoolst Cases excluded from school ......... Caaes treated in school! Cases instructed in school, or evidence of treatment furnished! Number of treatments! Number of instructions! . . • . Richmond Cases found in schoolst Cases excluded from school Cases treated in school! Cases instructed in school, or evidence of treatment furnished! Number of treatments! Number of instructions! 50 CD B E. ? M It B s H o Communicable diseases of eye and skin » n a* o B B*? B GO n p o* (* G " n C §2. M ■ o *Other contaffious eye diseases tThe general communicable diseases and trachoma by inspectors only; other diseases by nurses in schools where there are nurses, otherwise by inspectors !By nurses under prescribed directions !By nurses 98 Exhibit 4— Continued Table 37 Table 37 is intended to show, for inspection of contagious diseases in school children, the field covered (number of schools and registra- tion), the frequency of inspection (average visits per school per year), the number of examinations of children made, and finally the number of cases of disease discovered, these totals corresponding to those in Tables 35 to 36. In examinations of children and cases discovered, the work of the inspectors and of the nurses is presented separately. The frequency of visits is not given for the nurses because their work is more accurately judged on the basis of examinations and cases. Table 38 While the work of the nurses should show in the total results stated for all schools in the foregoing tables, the justification for their work would be brought out more clearly by a brief separate statement covering only the field in which their work lies. Table 38 is for the purpose of showing how far the two main objects of their work are attained (See page 93). Table 39 Table 39 shows, in reference to examination of school children for non-contagious physical defects, the field that should be covered (the total registration), the field that is covered, the number and proportion of those examined who are found to need treatment, and the number and proportion of those needing treatment who are known to have received it. Exhibit 4^Continued 99 Table 37 MEDICAL INSPECTION OF SCHOOL CHILDREN FOR CONTAGIOUS DISEASES, 1906 FIELD OF INSPECTION Total number of public schools Registration Public schools under inspection Registration Other schools under inspection Registration Total schools under inspection Total registration of schools under inspection. Schools in which there are nurses Registration VISITS TO SCHOOLS By inspectors to public schools By inspectors to other schools ▲▼eraiT* P«i^ ichool per year Public eohools Other sohool* EXAMINATIONS "Morning" examinations of children by in- spectors* General communicable diseases found "Routine" examinations by inspectors! Cases found, eye and skin diseases "Routine" examinations by nursest Cases found, eye and skin diseases Special "routine" examinations bv inspectors for trachoma Cases found Total general communicable diseases found in schools Total case* found in schools, eye and skin diseases VISITS TO HOMES By inspectors By nurses New York Man- hattan Bronx Brook- lyn Queens Rich- mond *In "morning** examinations, the inspectors examine the children referred to them by teachers or nurses as suspected cases, or children returning to school after absence on account of sickness t*'Routine*' examinations are made by nurses in schools where there are nurses, otherwise by inq>ectors. The entire class is examined to discover any cases of eye and skin diseases except trachoma, for which a special "routine" examination is made by inspectors only lOO Exhilnt 4 — Coniinued Table 38 PREVALENCE OF COMMUNICABLE EYE AND SKIN DISEASES IN SCHOOLS IN WHICH THERE ARE NURSES, AND PROPORTION OF EXCLUSIONS THEREFOR, 1902-1906 New York City 1902 .... 1903 .... 1904 .... 1905 .... 1906. .. . Manhattan 1902. . . . 1903. . . . 1904 .... 1905. . . . 1906. . . . Bronx 1902. . . . 1903. . . . 1904 ... . 1905. . . . 1906. .. . Brooklyn 1902. . . . 1903. . . . 1904. .. . 1905. ... 1906. . . . , <2ueens 1902. . . . . 1903. ... , . 1904 .... , 1905. . . . . 1906 Richmond 1902 1903 1904 1905 1906 Registration* of schools in which there are nurses Cases found, eye and skin diseases Cas«s p«r 1,000 of r«fiatr»tloa Exclusions therefor Bxolusloiui PMT 1,000 Of roiristratioa I p 'Average of the registration on the last school day of each month Exhibit 4 — Continued loi Table S9 EXAMINATION AND TREATMENT OF SCHOOL CHILDREN FOR NON-CONTAGIOUS PHYSICAL DEFECTS, 1902-1906 Comparative summary by years and boroughs NEW YORK EXAMINATION Total rcRistration 'in public schools Number of children examined Vorcontaffo of total roffistration Number needing treatment Foroentaffo of thoso examined needinir treatment TREATMENT Number known to have been treated Feroentaffe of those needing treatment known to haye been treated EACH OF FIVE BOROUGHS EXAMINATION Total registration in public schools Number of children examined Feroentaff e of total registration Number needing treatment Feroentage of those examined needinir treatment TREATMENT Number known to have been treated Feroentaffe of those needing treatment known to have been treated 1902 1903 1904 1905 1906 I02 Exhibit 4 — Continued Table 40 Any single child may of course be found to have several defects. Table 40 deals with the number of defects, not the number of children found defective. The figures, therefore, will not correspond exactly with any in Table 39. A comparison of the two will show, if desired, the average number of defects per child, both found and treated. Exhibit 4 — Continued 103 Table 40 MEDICAL EXAMINATION OF SCHOOL CHILDREN: NON-CONTAGIOUS PHYSICAL DEFECTS FOUND AND TREATED, 1906 New York Manhattan Bronx Found Beported treated Found Beported treated Pound Beported treated No. i of total defects Vo. No. ant. 1.- Ho. No. SB Ko. DEFECTS Adenoids Defective vision . . Defective hearing . Bad nutrition • . . Diseased anterior cervical glands . . Diseased posterior cervical glands . Chorea ...... Heart disease . . . Pulmonary disease Skin disease .... Deformity of spine . Deformity of chest . Deformity of extremities .... Nasal breathing . . Defective teeth . . . Defective palate . . Hypertrophied tonsils Defective mentality Total DEFECTS Adenoids Defective vision . Defective hearing Bad nutrition . • . Diseased anterior cervical glands . Diseased posterior cervical glands Chorea Heart diseaM Pulmonary disease Skin disease Deformity of spine Deformity of chest Deformity of extremities . . . Nasal breathing . Defective teeth . Defective palate . Hypertrophied tonsils Defective mentality ToUl I04 Exhihii 4 — Continued Table 41 See page 92 Table 42 The figures given in this table, when taken alone, of course mean little: they must be compared with the numbers of each class in the entire school registration. The figures are provided for, however, at the suggestion of a department official, and in connection with figures obtainable from the department of education might be of value. Exhibit 4— Continued ►tf o <» o o ^ O n ►T3 n •1 o n 9 » oq o a g. 3 < 3 3 S m o •t n .*• a^ 9 O 3 n 9* 9 o c 9 O. 9 n ft O. 9 o »* 5 n 9 3 9 9* a> » a td o 8 E o c o 9* B o 9 2; > H < H O n O o r o r w l-H o H W > I H N4 I. 2 » I > rt 2. I I I o I CD o 9" O O a: e I "< 9 »n o <» 9 p. 9»9 5.0 55 ««■ o S-0*9 (i n o 0> O e 9 9» ca »•■ 9* •1 14 • 1 «. pi •0 p h ? 2 2 !t «. 0. • » r*0 5'-' 9 w n o 0.9 • 1 0i Ht. Not promoted «. Discon- tinued o SI 09 n 0< CA n 9* O o O O H t-^ O aj CO > o O n W > w > § Hi « « o o > d w 5J o o "I los io6 Object Activities Relation of Activities to Object Exhibit 4 — Continued SUMMER CORPS To diminish the prevalence of diarrheal diseases during the summer months among children under two years of age. Investigation and inquiry by medical inspectors and nurses to discover cases of diarrheal diseases, and treatment or instruction of cases not attended by pri- vate physicians. The work done is largely educational, consisting of furthering intelligent care and feeding of babies. While attention is primarily directed towards the care of babies already sick, the instructions given should operate both to prevent recurrence of sickness and to avert new cases. The work is thus both preventive and curative. Since diarrheal diseases are not among those regu- larly reported to the department, figures to show their prevalence are difficult to get. The visits of the inspectors and nurses, however, constitute when tabulated an approximate census in the districts cov- ered; on this as a basis can be stated the proportion of cases found to the total number of children re- corded (Table 43). Tables 44-46 Tables 44-46 are compiled from the daily inspection records. They show the relative prevalence of the different methods of feeding, and the proportion of sickness and deaths accompanying each. Exhibit 4^Continued &: fr Q s n ■" (A (4 c w C n Gl. 5. Or S o a* 0) B K t— ( n w r r > w o c O > •-) A • a> 2 N — 9 it- 5 1 5 H •-J n n B ft (0 n n "^ o 5. ^ n O 12 O » S o : c o< r» , cr - V! B ■-» CA .i.* 2 ■< *< CM 2 2 (0 B n « en O o i m o •So- S B HI P i B o 5- Si — . ... 2 B 2 '» B (L rt B Si » o 5" W o B Inspectors Nurses f» O Inspectors Nurses Inspectors p B B* » » B O B H Nurses Inspectors Nurses Inspectors Nurses Inspectors Nurse s u ►i O o K B o B n B o B* B o B 107 o o S o* ^ io8 Exhtbii 4— Continued Exhibit 4— Continued 109 r Table 44 SUMMER CORPS: SUMMARY, 1902-1906 1902 1903 1904 1905 1906 Children visited Cases of diarrheal diseases found Cases per 1,000 children visited Children treated by department Table 45 METHODS OF FEEDING OF CHILDREN REGISTERED BY SUMMER CORPS, 1906 Breast fed Milk: modified , Milk: boiled at home Milk: pasteurized, Straus Milk: pasteurized, commercial. Milk: condensed Patent food Table food Raw fruit Mixed feeding Total Under 9 months Over 9 and under 24 months No. toUl With dlar. dls. Vo. No. *of total With dlar. difl . Vo. Table 46 METHODS OF FEEDING OF CHILDREN DYING FROM DIARRHEAL DISEASES AND INVESTIGATED BY SUMMER CORPS, 1906 Breast fed Milk: modified Milk: boiled at home Milk: pasteurized, Straus Milk: pasteurized, commercial. Milk: condensed Patent food Table food Raw fruit Mixed feeding Total Under 9 months No. i of total Over 9 and under 24 months No. i of total VACCINATION To reduce to a minimum the prevalence of small- pox. Vaccination of as many people as possible at suffi- ciently frequent intervals. Vaccination is carried out: (a) By a corps of school vaccinators who spend all their time in vaccinating children in the public schools. They make a com- plete circuit of the public schools in from four to five years (Table 47). (b) By school medical inspectors, who vacci- nate on Saturdays and school holidays, and during vacation in districts assigned to them; by the summer corps, wherever the inspectors happen to find cases need- ing it; by physicians at the department offices ; by a special vaccinator on Black- well's Island; and by the hospitals, which vaccinate those entering for what- ever cause. Miscellaneous vaccinations may be performed by other members of the department (Table 48). If everybody were vaccinated effectively and at sufficiently frequent intervals (once in four years), there would be a minimum of small-pox; in general, the higher the percentage of the people in the city who are vaccinated, the lower will be the case rate and death rate of small-pox. But other factors enter in: district medical inspection in the early discovery and diagnosis of the disease; disinfection; and hos- pital care, which is both preventive and curative. It is to be noted that in vaccination more than in most other lines of work under consideration, judg- ments are not valid unless based on figures for long periods, for the reason that immunity may persist con- Object Activities Relation of Activities to Object no Exhibit 4— Continued siderably longer than four years; and because, sec- ondly, even if immunity does sink to a lower point, a serious exposure of the city to the disease may not occur for several years. Hence statements of small-pox prevalence covering short periods are practically valueless as an index to the efficiency of vaccination. The only way of knowing how many persons at any given time need vaccination is so far from accurate as to be of little value. As the work of the department is organized, how- ever, it is possible to give figures to show what pro- portion of the school population has been examined in any one year and either vaccinated or found not needing vaccination. For the rest, since no popula- tion figures are available for the districts in which the vaccinations are made, the best that can be done is to express the total number of vaccinations (includ- ing those in schools) as a percentage of the total population. This percentage, when compared with the case and death rate for a considerable number of years, may work out a standard of the proportion of the population necessary to vaccinate annually. Exhibit 4— Continued III Table 47 VACCINATIONS IN SCHOOLS, 1906 FIELD OF WORK Total public school registration Re^stration in schools covered by school vac- cinators during 1906 WORK PERFORMED Children examined Children vaccinated by department physicians. Children vaccinated by other physicians Children not requiring vaccination Fereentagre of children examined to total ■cliool reflristration New York Man- hattan Bronx Brook- lyn Queens Rich- mond Table 48 TOTAL VACCINATIONS BY DEPARTMENT OF HEALTH, 1906 Vaccinations in public schools* in other schools ** in districts •• at offices " at Blackwell's Island ** at hospitals •• by summer corps Percentasra of vaccinations to total esti- mated population f Total vaccinations New York Man- hattan Bronx Brook- lyn Queens Rich- mond *By special vaccinators and by school inspectors tPossible duplications included Table 49 VACCINATIONS BY DEPARTMENT OF HEALTH, 1902-1906 1902 1903 1904 1905 1906 Vaccinations by department of health Per cent, of estimated population 112 Object Activities Relation of Activities to Object Exhibit 4— Continued DISINFECTION To assist district medical inspection in diminishing the prevalence of contagious and communicable diseases. (a) Disinfection, as ordered by medical inspectors, of rooms or houses which have been occupied by cases of the following contagious diseases: small-pox, diph- theria, scarlet fever, measles; by cases of the follow- ing communicable diseases: tuberculosis, typhoid fever (on request of physicians), cerebro-spinal men- ingitis; and disinfection of stables occupied by cases of glanders in horses. (b) Disinfection, as ordered by medical inspectors, of bedding and other goods infected by cases of the above diseases. In all the contagious diseases mentioned and in cerebro-spinal meningitis, disinfection, though it does not possess an equal value, is now an accepted prac- tice; in general, all cases are supposed to be disin- fected at their termination either in private houses by physicians (except small-pox) or by the depart- ment. In tuberculosis, disinfection is freely employed, chiefly following deaths, removals from one address to another, from the city and to hospitals or sanatoria. In typhoid, disinfections are performed only at the request of physicians. In glanders of horses, since the period of possible contagion is indefinitely long, and since in practice it proves impossible to find any stated proportion of infected stables, no formulation is possible. It is hardly feasible to demonstrate the value of dis- infection statistically through the ordinary depart- mental routine ; for that purpose, a special experiment would have to be arranged, in which the conditions were more thoroughly under control. In regular re- ports, the work performed is all that it is practicable to show. Exhibit 4— Continued "3 Table 50 DISINFECTION OF PREMISES, 1906 DISINFECTIONS PERFORMED » Scarlet fever Diphtheria ...,.•• . . . . Measles Small-pox Tuberculosis Typhoid • • . . . Cerebro-spinal meningitis Glanders of horses Miscellaneous Total 'Number of visits, disinfection not performed. Number of rooms disinfected New Man- York hattan Bronx Brook- lyn Queens Rich- mond * The disinfections performed, as shown in Tables 50-51, will correspond with the disinfections ordered, as given in the tables for district inspection in the division of contagious and communicable diseases, with the qualification that disinfections in upper Manhattan may for convenience be per- formed by Bronx disinfectors Table 51 GOODS DISINFECTED OR DESTROYED, 1906 New York Man- hattan Lots of goods* on hand Jan. 1, 1906 Received during 1906 By order from divisions of contagious and communicable diseases From hospitals Miscellaneous Total during 1906 Lots of goods disinfected Lots of goods destroyed LoU of goods on hand Dec. 81. 1906 Number of articles disinfected Number of articles destroyed Bronx Brook- lyn Queens Rich- mond * A "lot of goods" consists of all the articles removed for disinfection or deatructioB at the jdote of a case 114 Exhibit 4 — Continued Object Activities Relation of Activities to Object ANIMAL INSPECTION To prevent the spread of contagious diseases, chiefly glanders, rabies, and tuberculosis, among animals, thus indirectly protecting the public health. Inspection of suspected cases of these diseases; destruction of those diagnosed as true cases; ordering of disinfection (glanders). Success in this line of work would theoretically show in a decreasing prevalence of the diseases men- tioned. As it is impossible, however, to get with accuracy the number of animals in the city, the best that can be done is to report the absolute numbers of cases occurring, inspected, and disposed of (Table 53). The number of disinfections ordered will have no fixed relation to the number of cases found, since some cases involve several disinfections, while in others the stables cannot be located. DEPARTMENT STABLES The same qualification as in Tables 50-51 holds in Table 53 with reference to the calls of ambulances and goods wagons. The calls in upper Manhattan may be made by the Bronx drivers. The last part of the table is designed to show the amount of horse service maintained. Exhibit 4— Continued 115 Table 52 ANIMAL INSPECTION, 1906 HORSES Examinations of horses Horses tested with mallein Glandered horses condemned and destroyed .... Post-mortem examinations of horses Inspections of stables Disinfection of stables ordered DOGS Examinations of dogs Animals referred to research laboratory for diagnosis of rabies Cases of rabies cows Examinations of cows Cows tested with tuberculin Cows condemned MISCELLANEOUS Examinations of other animals New York Man- hattan Bronx Brook- lyn Queens Rich, mond Table 53 DEPARTMENT STABLES, 1906 AMBULANCE DRIVERS Cases removed to hospitals Bodies removed to morgue Other visits made Total visits Number of times ambulances or other vehicles disinfected GOODS WAGON DRIVERS Visits, infected goods removed Visits, disinfected goods returned Other visits made Total visits STABLE SERVICE Average number of horses cared for* For ambulances and goods wagons For executive officials Total days care for all horses For ambulance and wagon horses For horses of officials New York Man- hattan Bronx Brook- lyn Queens Rich- mond 'Average of those under care on the lit of each month ii6 Object Activities Exhibit 4 — Continued DIVISION OF COMMUNICABLE DISEASES To diminish the prevalence of the diseases classed as "communicable," by both preventive and curative means. The main emphasis has so far been placed by the division upon tuberculosis, diphtheria, typhoid, and cerebro-spinal meningitis; in pneumonia, malarial fever, erysipelas, and puerperal septicaemia, the work of the division has not yet been developed to any considerable extent. The activities of the division vary so with the dif- ferent diseases concerned that a separate statement is required for each disease. TUBKRCUI.OSIS Registration. Obtaining and recording the essen- tial facts in all known cases in the city; tracing of cases to keep records up to date (Table 56). District Inspection. Visits by inspectors where disinfection is likely to be necessary (deaths, cases removing from city, to hospitals or sanatoria, or to other addresses) and to cases at home, on com- plaint; reference of appropriate cases to hos- pitals and sanatoria; compulsory removal to hos- pitals, when necessary; renovation of habitations (through the division of inspections) ; ordering of disinfection (Table 58). Weekly visits by nurses to cases at home requiring to be kept under observation (Table 58). Clinics. Early recognition and diagnosis of cases; reference of cases to hospitals and sana- toria; supervision of patients in their home (Table 59)- Diphtheria Injection of antitoxin; intubation of laryngeal cases needing intubation; immunization of well persons exposed (Table 61). Exhibit 4 — Continued Typhoid Cerebro-spinal meningitis Inspection; requiring of precautions against infec- tion (analagous to maintenance of quarantine) ; ordering of disinfection; investigation of sources of infection (Tables 63-64). 117 Malariai. fever Pneumonia Investigation of death reports to verify cause (Table 65). ErYSIPEIvAS PuERPERAi, Septicaemia Only recording deaths as reported (Table 65). Diagnosis I^aboratory The diagnosis laboratory provides free exam- ination of and report upon specimens submitted to it for diagnosis. The terms in which health results may be measured vary also with the disease. In tuberculosis, significant figures are difficult to get. It is only since 1897 that tuberculosis has been included among the diseases compulsorily reported to the department of health. Since that time, until 1906, there has been an almost steady rise in the num- ber of cases reported, a rise probably due in the main to increased thoroughness of reporting. 1906, how- ever, showed a decrease over 1905 in the number of cases reported, and it is not unlikely that a sufficient completeness in reporting has been reached to make the number of new cases reported (per 1,000 of popu- lation) a fairly reliable standard (Table 54). The Activities Relation of Activities to Objects Tuberculosis Case Rate f ii8 Diphtheria Case Rate Typhoid Case Rate Other Case Rates Exhibit 4— Continued death rate from all tuberculous diseases and pulmon- ary tuberculosis can be used as a check. Another in- dex of progress in the campaign against tuberculosis is the death rate of children under 15 from pulmonary tuberculosis and tubercular meningitis, "the two forms of tuberculous diseases in which an approxi- mately accurate diagnosis is likely to be made in chil- dren. It is in this, the youngest element of the popu- lation, that one would first look for definite results from the enforcement of measures for the restriction of this disease" (Table 55). In diphtheria, the success of the antitoxin method is seen in the falling case fatality for a series of years (Table 60). The efficiency of antitoxin injection by the division may be judged by comparing the case fatality of the cases treated with the general case fatality, and with the case fatality of the cases treated by private physicians with free antitoxin. In im- munization, the number of persons immunized who contract the disease between two and thirty days after exposure can be given ; but of course there is no way of knowing how many would have contracted the disease without immunization (Table 61). In typhoid fever and cerebro-spinal meningitis both the case rate and death rate are of value (Table 62). In pneumonia, malarial fever, erysipelas, and puer- peral septicaemia, since no organized work is main- tained which would affect the public health, no vital statistics are given. The diagnosis laboratory being a subsidiary line of work no health results can be directly traced to its work. The report records the specimens examined and the results of examination (Table 66), together with the number submitted by members of the depart- ment and by private physicians respectively (Table 67). *BiM:«, "Administrative Control of Tuberculosis," p. 28 Exhibit 4 — Continued 119 Table S4 TUBERCULOSIS: GENERAL FIGURES, 1897-1906 Year New York 1897. 1898. 1899. 1900. 1901 . 1902. 1903. 1904 . 1905 . 1906. Manhattan 1897. 1898. 1899. 1900. 1901 . 1902 . 1903 . 1904. 1905. 1906. Bronx 1897. 1898. 1899. 1900. 1901 . 1902 . 1903. 1904. 1905. 1906. Brooklyn 1897. 1898. 1899. 1900. 1901 . 1902. 1903. 1904 . 1905. 1906. Queens 1897. 1898. 1899. 1900. 1901 . 1902 . 1903. 1904 . 1905. 1906. Richmond 1897. 1898. 1899. 1900. 1901 . 1902. 1903. 1904. 1905. 1906. w d e o (A ^1 0.0 2. O OB n " » n «> CA 3* in rv M << " 3* ^ B •♦ 2 O B* CB ft 0) •O B* r*- Bf CD* .^* CB o HI « 10 fei o • p" r =. (1 H CI* B n o S- o s^ P "2. '^ 3* O 3* » to CB 9 g* 3* ft » 3* (B o B O* ft "I n 2.2-0 StJB* ^ ft m B o •-» o o P 2. • - o *Bxcludins duplicates I20 Exhibit 4— Continued Table 55 DEATHS FROM PULMONARY TUBERCULOSIS AND TUBERCULAR MENINGITIS, 0-15 YEARS, 1897-1906 - 5 li ii New York 1897. . 1898. . 1899. . 1900 . . 1901 . . 1902. . 1903. . 1904 . . 1905 . . 1906. . Manhattan 1897. . 1898. . 1899. . 1900 . 1901 . . 1902. . 1903. . 1904. . 1905. . 1906. . Bronx 1897. . 1898. . 1899. . 1900. . 1901 . . 1902 . . 1903 . . 1904 . . 1905. . 1906. . Brooklyn 1897. . 1898. . 1899. . 1900. . 1901 . . 1902. . 1903. . 1904. . 1905. . 1906. . Queens 1897. - 1898. . 1899. . 1900. . 1901 . . 1902. . 1903. . 1904. . 1905. . 1906. . Richmond 1897. . 1898. . 1899. . 1900. . 1901 . . 1902. . 1903. . 1904 . . 1905. . 1906. . Pul. tub. Tub. men. 5 - 10 Pul. tub. Tub. men. 10-15 Pul. tub. Tub, men. Total tinder 15 Pul. tub. Tub. men. Total. both. under 15 Deaths, both, par 1,000 of popula- tion Exhibit 4— Continued 121 Table 56 TUBERCULOSIS REGISTER: LIVING CASES, 1906 Cases enrolled January 1, 1906 Under care of private physicians Under care of dispensaries or clinics* At home and under supervision of department. In institutions in city In institutions outside city Not found at address given;t 1904 and 1905 New (living) cases reported By physicians By sputum By institutions Total living cases enrolled in 1906 Cases removed from register in 1906 Deaths Removals from city Not found;! held for 2 years Recovered Cases enrolled December 31, 1906 Under care of private physicians Under care of dispensaries or clinics At home and under supervision of department. In institutions in city In institutions outside city Not found at address given;t 1905 and 1906.. Total Man- hattan Bronx Brook- [Queens Rich- lyn I mond •Other than the department clinics tHeld in current register 2 years; after that time, removed to files I( II 122 Exhibit 4 — Continued Table 57 As is seen in Table 56, cases of tuberculosis are classified for ad- ministrative purposes in six groups. The cases visited by the inspectors may be found in almost any of these: no exact statement is made of the number of cases which they might be expected to visit. The deter- mination of whether or not they visit all the cases that they should is for the present a matter for the current office records. In two other main lines of the division's work, however, a standard is possible. The "at home" file, which contains the cases on which the work of the district nurses and of the clinics is done, is capable of the same form of statement as a hospital — substituting "at home" months for patient days. If 10 patients are "at home," one for 2 months, one for 3 months, etc., a total of 50 months for all, while the district nurses keep under observation during that time one patient for i month, one patient for 2 months, etc., a total of 15 months, and if the clinic also has under treatment patients for a total of 20 months, then 30% repre- sents the proportion of the "at home" field covered by the district nurses, 40% the proportion covered by the clinics, and 70% the propor- tion covered by both. It is quite probable that it is unnecessary to keep the entire "at home" group under constant observation or treat- ment. The above percentages, however, given year by year, would work out a standard on the basis of experience. Exhibit 4— Continued 123 Table 57 SUMMARY OF DISTRICT INSPECTION OF TUBERCULOSIS AND OF TREATMENT BY THE DEPARTMENT CLINICS, 1906 TOTAL MONTHS MX "AT HOM^" CASES Months "at home" cases under observation by district nurses Pero«ntair« of total months Months "at home" cases under treatment or observation by department clinics F«rc«ntair« of total months Months "at home" cases under observation or treatment by both district nurses and clinics . . . Fsrcontaffo of total months all "at homo" oasos New York Man- hattan Bronx Brook- lyn Queens Rich- mond X14 Exhibit 4^Continued Table 38 It may be expected that the numlDer of disinfections ordered will have an approximate (though only an approximate) correspondence with the number of premises visited on account of deaths or removals. The average frequency of visits by nurses to cases under observa- tion is worked out in the same form as that employed in Table 57. If as is expected, they visit each case once a week, the average visits per month per case under observation will be approximately 4. Table 39 In Table 59, the item, "Old cases coming under treatment in 1906," is introduced in order to make an exact balance with the number of dispositions made of cases given immediately below. As the same case may be sent to a hospital or otherwise disposed of several times during a year, it is necessary to provide as above for the duplicate entries. The "total," therefore, does not represent the number of different per- sons under treatment during the year : if this figure is desired, it can be obtained by adding the items "Under treatment January i" and "New cases coming under treatment in 1906." The average frequency of clinic treatment and of visits by nurses to cases kept under observation is shown by means of the same form of statement as is employed in Table 57. As the cases kept under ob- servation by the nurses are expected to be visited once a week, the item "Average visits per month per case under observation'* will pre- sumably be found to be about 4. Exhibit 4— Continued 125 Table 58 TUBERCULOSIS: DISTRICT INSPECTION, 1906 INSPECTORS Premises visited on account of deaths* Cases removing to hospitalf Cases removing from city t Cases changing address! Cases "at home" visited on complaint Total cases inspected Visits to cases inspected Visits to investigate or trace cases Total visits by inspectors NURSES Total months all "at home" cases nnder obserration by district nurses Visits to cases *'at home" nnder obser- vation Averagre visits per month per case "at home" under observation Visits to investigate or trace cases Total visits by district nurses DISPOSITION OF CASES Forcible removals to hospital References of cases to hospitals References of cases to charitable organizations. Renovations compelled by inspectors' complaints Renovations made voluntarily Disinfections of premises ordered Disinfections of goods ordered New York Man- hattan Bronx Brook- lyn Queens Rich- mond 1 •From any one of several files, or not previously reported tFrom any one of several filet ' I ; i I'll 126 Exhibit 4 — Continued Table 59 TUBERCULOSIS CLINICS, 1906 New York DIAGNOSIS Under observation for diagnosis Jan. 1, 1908.. New patients examined during 1906 Total Found not tubercular and transferr-d or dis- charged Found tubercular Diagnosis tubercular, sputum positive Diagnosis tubercular, sputum negative Under observation for diagnosis Dec. 81, 1906.. Total CASES UNDER TREATMENT Under treatment Jan. 1, 1906 New cases coming under treatment in 1906 .... Old cases coming under treatment in 1906 .... Total Man- hattan Bronx Deaths Transferred to other clinics Transferred to hospitals Transferred to sanatoria Discontinuing, not found Discontinuing, not coming for treatment. Under treatment Dec. 31, 1906 Total Total months all paticnta under traatmant by clinics Total treatments of patients Average treatments per month per patient Largest number of patients in 1 day Smallest number of patients in 1 day Average number of patients in 1 day VISITS TO CASES Total months all patients nnder ohserva- tion by clinio nurses ▼isits to patients under observation .... ▲verag'e visits per month per case under observation Other visits to cases under clinic treatment.... Total visits by clinic nurses Visits by clinic physicians MISCELLANEOUS Prescriptions filled for clinic patients Quarts of milk supplied to clinic patients. Eggs supplied to clinic patients Brook- lyn Exhibit 4 — Continued 127 Table 60 DIPHTHERIA: GENERAL FIGURES, 1897-1906 Year Mew York 1897. . 1898. . 1899. . 1900. . 1901 . . 1902. . 1903. . 1904. . 1905. . 1906. . Manhattan 1897. . 1898. . 1899. • 1900. . 1901. . 1902. . 1903. . 1904. . 1905. . 1906. . Cases reported Bronx 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 Brooklyn 1897. 1898. 1899. 1900. 1901. 1902. 1903. 1904. 1905. 1906. Queens 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 Cases per 1,000 of population Richmond 1897. . 189S. . 1899. . 1900. . 1901 . . 1902 . . 1903. . 1904. . 1905. . 1906. . Deaths population \ p^^ cent. Deaths per 1,000 of Case fatality Per cent, of cases reported, iaj acted at home by dept. of health I 128 Exhihii 4— Continued Table 61 DIPHTHERIA: INJECTION, INTUBATION, AND IMMUNIZATION, 1906* INJECTION OF ANTITOXIN Cases of diphtheria reported Cases injected by dept. inspectors Percentage iajeoted by dept. ixispectorfl . . Cases injected by private physiciansf Peroentair* iajeoted by private phyalolans By department inspectors Cases injected Deaths Case fatality, per cent Deaths, moribund^ deducted Case fatality, per cent., moribund % de- ducted By private physiciansf Cases injected Deaths Case fatality, per cent Deaths, moribund^ deducted Case fatality, per cent., moribund % de- ducted . , INTUBATION OF LARYNGEAL CASES Cases injected by dept. inspectors Total laryngeal cases Deaths Fatality per cent Cases intubated Deaths Fatality per cent Cases not intubated Deaths Fatality per cent IMMUNIZATION By department inspectors Number immunized Number contracting disease between 8 and 80 days VISITS Total visits to diphtheria cases Average visits per case Total injections New York Man- hattan Bronx Brook- lyn Queens Rich- mond Exhibit 4 — Continued 129 Table 62 TYPHOID AND CEREBRO-SPINAL MENINGITIS: GENERAL FIGURES. 1897-1906 New York City: cases reported, case rate, and death rate •Quarantine is maintained and disinfections are ordered by the division of contagiouA diaeases tWith antitoxin furnished free by the department^ of health tCases dying within 24 hours after injection Typhoid 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 Cerebro-spinal meningitis 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 Cases reported Cases per 1,000 of population Deaths Deaths per 1,000 of population I30 Exhibit 4 — Continued Table 63 TYPHOID FEVER: GENERAL FIGURES AND INSPECTION, 1906 Cases reported Oases per 1,000 of popnlation Deaths from typhoid Case fktallty, per cent Deatlis per 1,000 of population Cases not inspected on account of detailed re- port by attending physician Cases inspected Total •..-...•• Visits to cases Disinfections of goods ordered New York Man- hattan Bronx Brook- lyn Queens • Rich- mond Table 64 CEREBRO-SPINAL MENINGITIS: GENERAL FIGURES AND INSPEC- TION, 1906 Cases reported Cases per 1,000 of population . . . Deaths Case fatality, per cent Deaths per 1,000 of population Cases visited Visits to cases Disinfections of premises ordered . . . Disinfections of goods ordered New York Man- hattan Bronx Brook- lyn Queens Rich- mond Exhibit ^—Continued 131 Table 6$ SUMMARY OF INSPECTIONS, VISITS, ETC., DIVISION OF COMMUNICABLE DISEASES, 1905-1906 Tuberculosis Diphtheria Typhoid Cerebro-spinal meningitis Malarial fever Pneumonia Brysipelas Puerperal septicaemia . Other Total Cases visited 1905 1906 Visits to cases Inspectors 1905 1906 Nurses 1905 1906 Disinfections ordered, 1906 Premises! Goods Re- movals to hos- pitals, 1906 A 132 Exhibit 4— Continued Table 66 DIAGNOSIS LABORATORY: SPECIMENS EXAMINED AND RESULTS OF EXAMINATION, 1906 DIPHTHERIA Bacteriological examinations for diaKnosis Showing Klebs-Loc£fler bacilli , Not showing Klebs-Loeffler bacilli , Indecisive Later cultures Other cultures Total cultures TUBERCULOSIS. SPUTUM Specimens examined Showing tubercle bacilli Showing no tubercle bacilli ........... TYPHOID Widal Reaction Specimens of blood examined Showing reaction Showing no reaction Indecisive Diazo Reaction Specimens examined Showing diazo reaction Showing no diazo reaction Showing doubtful reaction MALARIA Specimens examined Showing malaria plas Showing no malaria plas MISCELLANEOUS Average number of culture stations* Visits to collect specimens Culture tubes prepared Swabs made Laboratory preparations made New York Man- hattan Bronx Brook- lyn Queens Rich- mond Exhibit 4 — Continued 133 Table 67 DIAGNOSIS LABORATORY; SPECIMENS SUBMITTED FOR EXAMINATION, 1906 Diphtheria .... Tuberculosis • . . Typhoid Widal reaction Diazo reaction Malaria Total Percentage .... Number of specimens submitted for diagnosis by Department of health Private physicians 'Average of those in operation on the first of each month 134 Exhibit 4 — Continued Objects Activities Relation of Activities to Object HOSPITALS FOR GENERAL INFECTIOUS DISEASES (a) Preventive. To remove cases of contagious diseases from the imperfect quarantine of a home to the relatively perfect isolation of a hospital. (b) Curative. To provide treatment. The proper treatment and disposition of the cases received. The contribution of a contagious disease hospital to prevention can be measured only when some change of policy occurs in committing cases to the hospitals. For example, if the scarlet fever pavilion at Willard Parker hospital is enabled to receive a much larger percentage than formerly of the cases oc- curring in Manhattan, it will be fair to expect the prevalence and death rate of that disease to fall off perceptibly in the next five years. Improved methods of treatment, such as that of diphtheria by antitoxin, show in a decreased case fa- tality over a series of years. Table 68 Table 6S indicates what proportion of the total cases of contagious diseases reported the department cares for in its hospitals. The open- ing of a new ward or pavilion is reflected in the increased proportion of cases cared for, and gives a basis for judging the contribution of the hospitals to the prevention of disease. Exhibit 4— Continued fM p» ^rf ^^ ^^ Wilt f 3 s> a SB M 2 n '»-••-• t_i )_■ SB CA o > ft-' h-« l-rf ^^ O Jn Jn ^ ^ *"" £• ^ ►- •-> ^- ^ .tn. 'MN> B C/i * C*> NJ13 o M I? SB C/l .& t»J Ki f* ' tn & Cm l\> < n < n CT\ tn S C*i ro ;i 135 M 1 tn 5? 3 s > i 1 f' ^ ft 2 ^ - — — 2. >d ft ft ^J K- s - ^■ rS- 8 S « ^ s H ^ ^ xjS. ^ ^ H 2*B» p. SB » < a ^ n 0. ^ ^ ft CONT rcentage ^ 1 = > GIO f tota 3 S S DISEA ses reporte ated in hos Each boro • cot) ^ W ^ s-s; ? « B» ■ CO ♦ Ill 136 Exhibit 4—Oontint^cl Tobies 69-84 Table 69 summarizes Tables 70-74, which are practically the present forms of statement of patients received and discharged. Tables 75-79 show the high and low extremes of demand for hospital care; also the average number of patients for each of five hospitals. Tables 80-83 give for each hospital (except Otisville, for which it would be without significance) the case fatality by age periods, accord- ing to the duration of the disease previous to admission. It may be expected that the figures will prove a lower fatality in cases of early admission. Table 84 is intended to show to what extent the hospitals may be responsible for infections among patients after admission. Exhibit 4— Continued 137 Table 69 ALL DEPARTMENT OF HEALTH HOSPITALS: PATIENTS DURING 1906 Diphtheria Scarlet fever Small-pox Chicken-pox ....•• Measles * • • . Mumps Tuberculosis German measles Whooping cough Diphtheria and scarlet fever Diphtheria and chicken-pox Diphtheria and measles Diphtheria and German measles Diphtheria and whooping couRh Diphtheria, scarlet fever, and measles Scarlet fever and whooping couch Measles and chicken-pox Measles and whooping cough Gonorrheal vaginitis complicating other diseases. Trachoma Total cases For observation Persons accompansring patient ?3 rS. t B So 1^ 3- (0 t 2: » • 0» PS 2. 5* f I I I II 138 Exhibit 4~'Continued Tables 70-74* HOSPlTALt: PATIENTS DURING 1906 Diphtheria Scarlet fever Small-i>ox Chicken-pox Measles Mumps Tuberculosis Oerman measles "Whoopingr cough Diphtheria and scarlet fever Diphtheria and chicken-pox Diphtheria and measles Diphtheria and German measles . . . Diphtheria and whooping: cough . . . Diphtheria, scarlet fever, and measles Scarlet fever and whooping cough . . Measles and chicken-pox Measles and whooping cough .... Gonorrheal vaginitis complicating other diseases Total cases For observation Accompanying Remain- ing Jan. 1, 1906 Admitted New Trans- ToUl ferred ^'^^'^^ from Dis- charged Died Trans- ferred to Remain- ing Dec. 31, 1906 Exhibit 4— Continued 139 ♦One each for Reception, Willard Parker, Riverside, Kingston Avenue, and Otisville t Only the diseases treated in each hospital being given in the first column Tables 73-79* HOSPITAL: SERVICE RENDERED, 1906! Patients Fatl«nt days Diphtheria . . . . Scarlet fever . . . Small-pox Chicken-pox . . . Measles German measles Whooping cough. Mumps Tuberculosis . . Mixed infections. Total For observation . Accompanying . . •One each for Reception, Willard Parker, Riverside, Kingston Avenue, and Otisville t Only the disease treated in each hospital being given in the first column Average days per patient Largest number patients at one time Smallest number patients at one time Average patients per day • S3 i 1 s? I 8 J?* o n 5' c o. 3 S* m 0* a 140 Exhibit 4^Continufd Table 84 CASES OF INFECTION WITHIN HOSPITALS, 1906 Cases of measles developing more than 14 days after admission Cases of scarlet ferer developing more than 10 days after admission Reception Willard Parker Riverside Kingston Kiversiae i Avenue Exhibit 4 — Continued 141 Table 8j OTISVILLE SANATORIUM: PATIENTS TREATED AND CONDITION WHEN DISCHARGED* 1906 NUMBER Incipient Moderately advanced Far advanced .... P«re«ntaff« Incipient Moderately advanced Far advanced .... Total cases treated in 1906 Discharged Deaths Appar- ently cured Arrested Im- proved Progres- sive 100 100 100 Under treat- ment Dec. 31 * The classification as to stage of disease, etc., is that adopted by the National Association lor the Study and Prevention of Tuberculosis Table 86 OTISVILLE SANATORIUM : DURATION OF PATIENTS' STAY, 1906 Total patients discharged, 1906 Length of stay , Under 1 month Over I month and under 3 months. Over 3 months and under 6 months. Over 6 months TabU 87 OTISVILLE SANATORIUM: PLACES TO WHICH PATIENTS DISCHARGED, 1906 Per cent. Totel fwtieBtt discharged, 1906 Patients discharged to their homes " « M pji,^, sanitoria... • •• .. ^ork at OtisviUe. Number F«reMit. 142 Object Activities Relation of Activities to Object Exhibit 4— Continued TRACHOMA HOSPITAL AND DISPENSARIES To cure cases of trachoma and other contagious eye diseases, chiefly among school children, and thereby to diminish their prevalence. Furnishing treatment (operative, post-operative, and non-operative) to the cases referred to it. The contribution of the hospital toward diminish- ing the prevalence of trachoma and other contagious eye diseases among school children cannot be sharply distinguished from that of the medical inspectors of schools and school nurses in discovering cases and urging treatment. The prevalence of trachoma and other contagious eye diseases given in Table 36 should show by its gradual decrease in a series of years the success of the combined work of the hospital, med- ical inspectors, and nurses. The direct cures of the hospital can be indicated by the percentage discharged apparently cured (Table 88), and by a special subse- quent investigation of these cases to discover the per- centage of permanent cures (Table 89). Exhibit 4 — Continued 143 TabU 88 TRACHOMA HOSPITAL AND DISPENSARIES: NUMBER AND PERCENTAGE OF APPARENT CURES, 1902-1906 CASES TREATED Trachoma : operative Trachoma : non-operative Other contagious eye diseases DISCHARGED APPARENTLY CURED Trachoma : operative Trachoma: non-operative , Other contagious eye diseases Peroantage of those treated discharged ap. pareutly otired Trachoma : operative Trachoma : non-operative Other contagriona eye diseases 1902 1903 1904 1905 1906 Table 8g TRACHOMA HOSPITAL AND DISPENSARIES: SPECIAL ANNUAL INVESTIGATION Number and percentage of permanent cures among patients discharged during 1906; investigation made (dates of duration) Discharged apparently cured Investigated Found No relapse Percentage no relapse to those found Same percentage, previous investigation Trachoma Operative Non-operative 144 Eahibit 4— Continued Table ^ TRACHOMA HOSPITAL AND DISPENSARIES: TREATMENT AND DISPOSITION OF CASES, 1906 CASES TREATED Under treatment January i, 1906. New cases treated in 1 906 Total treated in 1906 DISPOSITION Discharged apparently curedf Discontinuing before cure} Under treatment December 31, 1906. Total Trachoma By opera- tion* Non-opera- tive only F«rc«xitaff« of thoa* treated diseliarffed apparently onred Other conta- gious eye diseuset Total t X •With post-operative treatment following tit is suggested that no totals be entered for these items, since by combining several unlike quantities a false conclusion might be drawn iA patient is considered as "discontinuing" when he does not appear for 2 months Exhibit 4— Continued 145 Table 91 TRACHOMA HOSPITAL AND DISPENSARIES: EXAMINATIONS. DIAGNOSES, AND TREATMENTS, 1906 EXAMINATIONS Examinations for diagnosis. DIAGNOSES Cases rejected as non-contagious Cases found : trachoma Cases found: other contagious eye diseases. Total TREATMENTS Trachoma: operations Trachoma : post-operative Trachoma : non-operative Other contagious eye diseases. Totol Largest number in one day... Average number per day Hospital Dispensaries Total 146 Object Activities Relation of Activities to Object Exhibit 4— Continued RESEARCH LABORATORY With the exception of the administration of Pas- teur treatment, the research laboratory conducts a subsidiary line of work, and therefore has no direct health object. (a) Special bacteriological investigations. (b) Production of antitoxic serums and diagnostic toxins. (c) Bacteriological examination of specimens. (d) Administration of Pasteur treatment. The result of the work under (a) is shown in the special reports of investigations. For (b) and (c) there is a formal report of amounts produced and of specimens examined (Tables 92-93). (d) In judg- ing of the Pasteur treatment, as of the department's immunization by antitoxin injection, it is of course impossible to know how many persons would have contracted the disease if treatment had not been ad- ministered. All that can be stated is the number of persons treated and the number developing hydro- phobia (Table 94). Exhibit 4 — Continued 147 Table 92 RESEARCH LABORATORY: PRODUCTION OF ANTITOXIC SERUMS AND DIAGNOSTIC TOXINS, 1905- 1906 Units of diphtheria antitoxin produced (in thousands) Units of diphtheria antitoxin bottled for distribution(in thousands) Cubic centimeters of diphtheria toxin produced Units of tetanus antitoxin produced (in thousands) ......... Units of tetanus antitoxin bottled for distribution (in thousands) . Cubic centimeters of tetanus toxin produced Cubic centimeters of mallein produced Cubic centimeters of mallein bottled for distribution Cubic centimeters of tuberculin produced Cubic centimeters of tuberculin bottled for distribution Samples of toxins tested Samples of antitoxin serum tested 1905 1906 Table 93 RESEARCH LABORATORY: BACTERIOLOGICAL EXAMINATION OF SPECIMENvS, 1905-1906 Bacteriological examinations of water Bacteriolosrical examinations of milk Bacteriological examinations for virulence of diphtheria bacilli. 1905 1906 Table 94 RESEARCH LABORATORY : PASTEUR TREATMENT, 1905-1906 Patients under treatment Jan. 1 Patients under observation Jan. 1 * New patients treated during year Living: in New York City t Living outside of New York City X . • • . Attending laboratory for treatment Receiving vaccine by mail Total Patients developing hydrophobia . . . Patients not developing hydrophobia Patients under treatment Dec. 31 . . Patients under observation Dec. 31 • Total Number of injections in patients Animals diagnosed for rabies . . Cases Not cases 1905 1906 * Patients kept under observation for one month after close of treatment t Free Paying liS Exhibit '4^Coniinu^d Exhihii 4— Continued 149 Object Activities Relation of Activities to Object CHEMICAL LABORATORY As the chemical laboratory is a subsidiary line of work, no direct health object can be stated. Analysis of and report upon the specimens submit- ted to it. As there is no direct health object, nothing remains but to present a statement of the specimens submit- ted, so classified as to show by whom submitted (Table 95) and the results of analysis (Table 96). A statement is therefore added of the number of half days consumed in attendance at court for the purpose of testifying (Table 97). Table 95 CHEMICAL LABORATORY: SPECIMENS SUBMITTED AND ANALYZED, 1906 Total number of specimens analyzed Total number pieces of apparatus tested Total number reports forwarded and filed Specimens submitted . . . . By department of health Acetanelid Air Etc Total By police department Beer Opium Chloral Etc Total By department of water supply Water By department of street cleaning: Garbage Ash Etc Total , By Bellevue hospital . . . . By department of finance . . By department of correction By coroner By district attorney By county medical society . • 1905 1906 O Table g6 CHEMICA.L LABORATORY: RESULTS OF ANALYSES, 1906 The results of analyses may be siven as they are, at lengrth, in the annual report for 1905 Table 97 CHEMICAL LABORATORY : NUMBER OF HALF DAYS OF ATTENDANCE AT COURT, 1905-1906 1905 I 1906 January . . February " March • . . April . . . May. . . . June . . . . Jnly. . . . Auffust • • September October . . November December . Total. . . I50 Object Activities Relation of Activities to Object Exhibit 4 — Continued * VACCINE LABORATORY Like the other laboratories, the vaccine labora- tory is a subsidiary line of work and has no direct health object. (a) Production of vaccine virus. (b) Experimental testing of vaccine virus pro- duced. (c) Issuance, mainly to the chief clerk and to hospitals, of the virus as prepared for use. A formal statement is given of the amount of virus produced, tested, and issued. %. Exhibit 4 — Continued Table p8 VACCINE LABORATORY: VIRUS PRODUCED, TESTED, AND ISSUED 1905-1906 I5» PRODUCTION OF VACCINE VIRUS Gram collected Cubic centimeters of liquid virus prepared Spades charged with human- ized virus EXPERIMENTAL TESTING OF VIRUS Primary vaccinations Secondary vaccinations Visits MISCELLANEOUS Specimens of virus tested bacter- iolosrically Inspections of virus previously sold Animals vaccinated Animals collected from .... Autopsies on animals White mice injected other animals experimentedupon Mailing blocks prepared .... VACCINE VIRUS ISSUED Capillary tubes .... Small vials Large vials 1905 1906 To chief To cicT^ hospitals To miscel- laneous In exchange for old virus Total 1906 ToUl 1905 152 Exhibit 4 — Continued REMOVAI. OF DEAD ANIMALS, OFFAL, AND NIGHT SOIL The removal of dead animals, oifal, and night soil is done by contract, the contracts now in force being for five years. When an order to remove a carcase is forwarded to the contractors, the department, it is stated, keeps pressure upon the contractor till he reports the order executed. Relying upon the likelihood of other com- plaints from citizens if the order remains unexecuted, the department feels reasonably assured that the orders to remove are actually carried out. As to the other question, whether the removals (or trips for the purpose of removal) agree in number with the removals ordered, no at- tempt is made to determine. Carcases may be reported for removal to the contractors, either through the department headquarters or directly. The telephone number of the offal dock is in the telephone directory and there is nothing to prevent any citizen from communicating directly with the contractors, without the knowledge of the department. The only source of information, therefore, as to the amount of service ren- dered, is in the uncontrolled reports of the contractors. It is urged that the only way of furnishing data which would serve as an approximately reliable basis for bids, is to require all removal orders to go through the department office and to be there recorded, with the names and addresses of the citizens making the complaints, or of the inspectors ordering removal. The contents of the scows main- tained for the reception of night soil can be inspected and estimated before each trip. These records, when summarized and published an- nually, would provide facts on which a possible future bidder could base his estimate. (Table 99). .V Exhibit 4^ Continued 153 Table pp DEAD ANIMALS. OFFAL, AND NIGHT SOIL ORDERED REMOVED, 1906 CARCASES ORDERED REMOVED Large animals Horses "^ Mules I Donkeys j Colts I Ponies ) Cattle Other larsre animals Total large animals Small animals Calves Sheep I Goats ( Hogs 1 PiKS } Cats and dogs from streets Cats and dogs from public pound . . . . . Other small animals Total small animals Total all animals Greatest number any one week Large animals Small '* Smallest number any one week Large animals Small " QUANTITY OF MEAT, OFFAL, ETC, ORDERED REMOVED Pounds of meat *» »* «. poultry rabbits "fish " offal Total pounds Number of removals ordered of meat, offal, etc. Average pounds per removal Greatest number of pounds any one week . . Smallest number of pounds any one week . . QUANTITY OF NIGHT SOIL REMOVED Cubic yards of night soil removed New York Man- hattan Bronx Brook- lyn Queens Rich- mond 154 Ezhihit 5 u a eg es PQ Pi ^ 0*0 *- o Sr*' o z Q Z M to £ H g < S D CO 2: o iH 1(0 z Q « 0{gO o O C8 O fl W V. 1^ ll « ••- CO y s * 5 Sicca o' .a© « a «; 9 a i PQ M a o . a a cB °^ a 3-^ M a 2o ■2.2 a^ • 01 * (B . 4, . - • cn oj O a-2 ** S2 ** es (J a .2 t^jp-- ^ *2 *C H M S H S.S .S n 2 0^.2 4^ u u cn O V :s** ft « u a u«§.2o-3' « Q, ft O 4> S 2-2 -2 "oi" g^-oo3iaS|.5B^'£-HaS2_ Si=8.2«.2a-g§.2.2x.2-2«=£^ 0.2 o 4^ a S"^ o s.y C « O Jj (B ** it M « ^* I' O Oh * 5 a a .2 =»- o Ifi O C9-M « O 4; > u O O C p o CO 0} 0) « • 0) • fi O « u * ft o Si "^ 2 £«*: ^ M (Btu» QB '^^ 8 o o M a s I Exhibit 5 — Continued 155 I J^ w o Q W o H < O H P< O « CO 55 O U Q W CO Q ^: w W O H P$ O w p< o Q O w o o i o o u 8. H M (J o w u o H 04 W Q o a es ft a av 51 CO 3 w ig « (A O H < O A 3 ft O a s § 3 ^ M a *s «^ .c a 5 >. 2 S n OS tS o Xi a — u a ed u > Q CO o o o a o 4>l ft V Oi CB < ^ 2 S a T fc: s:= al a^ •" ^ .1 ** o «R "3 ft cn o J3 u o CO W < 06 t 2 o o < o H Q CO S I Q h O 00 0. 156 Exhibit 6 PROPOSED DETAILED CLASSIFICATION OF EXPENDITURES MADE BY THE DEPARTMENT OF HEALTH TO BE SHOWN BY THE SEGREGATION LEDGER I. GENERAL ADMINISTRATION 1. Commissioner Salaries and Wages Administrative Head Assistants Clerks Stenographers Office Boys Messengers Drivers Office and Other Expenses Expressage Books and Periodicals Furniture and Fittings Supplies Horse and Carriage Hire Auto Service Transportation Traveling Expenses 2. Secretary Board of Health Office of Secretary Salaries and Wages } ^ .,. »« r^cc 1 r\.\. r- ( ^^^ outline for commissioner Umce and Other Expenses J Exhibit 6 — Continued 157 Other Expenses Transportation Drawing Materials Supplies Sale of Anti-toxin and Virus Salaries and Wages Clerks Collectors Other Expenses Carfare Expressage Supplies EXHIBIT 6b 3. General Medical Officer Salaries and Wages Office and Other Expenses 4. Sanitary Superintendent Office of Sanitary Superintendent Salaries and Wages ) « .i- r r\cc A r\.A V- \ ^^^ outline for commissioner Office and Other Expenses \ Office Chief of Communicable Diseases Salaries and Wages ) c- i- r r\aL J r^^u >- > *^^^ outline for commissioner Office and Other Expenses J Office of Superintendent of Hospitals 1 See outline for commissioner 1 ) 1 See outline for commissioner See outline for commissioner Office of Chief Clerk Office Force Salaries and Wages ) Office and Other Expenses j Construction and Repairs Salaries and Wages Inspector in Charge Inspectors - See outline for commissioner Salaries and Wages Office and Other Expenses 5. Registrar of Records Salaries and Wages Office and Other Expenses 6. Corporation Counsel Salaries and Wages Office and Other Expenses II. BOROUGH OFFICES (The below given outline for each office will be used for the corresponding office in each borough) I. Assistant Chief Clerk Office force Salaries and Wages )^ ,. r r\ca 1 r^.l- r- iiiutt outliuc for coiiimissioner Office and Other Expenses ) See outline for commissioner I 158 Exhibit 6— Continued JExhibit 6— Continued 159 Care and Maintenance of Buildings Salaries and W«ges Janitor Engineer Watchman Laborers and Cleaners Repairs Building Plumbing Elevator Painting and Kalsomining Supplies Coal Engineers' Supplies Janitors' Supplies EXHIBIT 6c Undistributed Expenditure Postage Telephone Switch Board Operators 2. Assistant Sanitary Superintendent Executive Division Salaries and Wages ) ^^^ outline for commissioner Office and Other Expenses J Division of Inspections Executive Work Salaries and Wages Office and Other Expenses General Sanitary Inspection Salaries Incidentals Carfare Telephone Supplies Milk Inspection City Salaries Incidentals Carfare Telephone Supplies . See outline for commissioner i 1 Country ' Salaries Incidentals Carfare Telephone Supplies Food Inspection Salaries Incidentals Carfare Telephone Supplies Division of Contagious Diseases Executive Work Salaries and Wages Office and Other Expenses District Medical Inspection Inspectors Salaries Incidentals Carfare Telephone Supplies Nurses Salaries Incidentals Carfare Telephone Supplies ! See outline for commissioner EXHIBIT 6d Animal Inspection Salaries Incidentals Carfare Telephone Supplies i6o Exhibit 6 — Continued !i i School Inspection Inspectors Salaries Incidentals Carfare Telephone Supplies Nurses Salaries Incidentals Carfare Telephone Supplies Summer Corps Inspectors Salaries Incidentals Carfare Telephone Supplies Nurses Salaries Incidentals Carfare Telephone Supplies Disinfecting Stations Cost of Operation Salaries and Wages Other Expenses Chemicals Fuel Field Work Salaries and Wages Other Expenses Chemicals Care of Horses Repairs to Wagons and Harness Supplies ♦i 4> t Exhibit 6— Continued i6i Repairs and Betterments to Plant Miscellaneous Removal of Night Soil, etc. Support of Ambulance Service Abatement of Nuisances EXHIBIT 6e 3. Division of Communicable Diseases Executive Work Salaries and Wages \ ^^^ ^^^^j^^ ^^^ commissioner Office and Other Expenses District Medical Inspection Inspectors Salaries Incidentals Carfare Telephone Supplies Nurses Salaries Incidentals Carfare Telephone Supplies Clinics Salaries and Wages Nurses i Attending Physicians Medical Inspectors Hospital Clerks Laborers Other Expenses Carfare Telephone Drugs Supplies { I I I 162 Diagnosis Laboratory Salaries and Wages Assistant Director Bacteriologist Bacteriological Diagnostician Laboratory Assistants Clerks Laborers and Cleaners Laboratory Expense Culture Tubes Slides Wooden Boxes Sputum Jars Apparatus 4. Assistant Registrar of Records Salaries and Wages Office and Other Expenses EXHIBIT 6f III. LABORATORIES I. Research Laboratory Administration and Research Salaries and Wages Administrative Head Research Assistants Cleaners and Laborers Other Expenses Transportation Traveling Expenses Expressage Books and Periodicals Supplies Production of Antitoxin Salaries and Wages Other Expanses Board of Horses Veterinarian's Fees Guinea Pigs, Cost of Meat and Eggs Animal Food Apparatus Supplies Exhibit 6 — Continued » See outline for commissioner 4 •1 Exhibit 6— Continued Production Pasteur Virus and Treatment of Disease Salaries and Wages Other Expenses Cost of Rabbits Animal Food Apparatus Supplies Milk Analysis Salaries and Wages Other Expenses Bottles Petri Dishes Diagnosis of Glanders Salaries and Wages 2. Chemical Laboratory Administration Salaries and Wages Administrative Head Assistant Cleaners " Transportation Traveling Expense Books and Periodicals Expressage Supplies i6s Other Expenses t Water Analysis Salaries and Wages Other Expenses Apparatus Chemicals Supplies MUk Analysis Salaries and Wages Other Expenses Apparatus Chemicals Supplies i64 Exhibit 6 — Continued Exhibit 6 — Continued 165 EXHIBIT 6g Food Analysis Salaries and Wages Other Expenses Apparatus Chemicals Supplies Miscellaneous Work Salaries and Wages Other Expenses Apparatus Chemicals Supplies 3. Vaccine Laboratory Administration Salaries and Wages Administrative Heads Assistants Cleaners Other Expenses Transportation Traveling Expense Expressage Books and PerlOviicah Supplies Cost of Production of Vaccine Salaries and Wages Laboratory Assistants Inspectors Laborers and Cleaners Other Expenses Cost of Calves Cost of Food for Calves Instruments Supplies Repairs and Improvements ^< V 4. Drug Laboratory Salaries and Wages Chemists Laboratory Assistants Laborers and Cleaners Other Expenses Expressage Furniture and Fittings Apparatus Repairs Waste Drugs, and Supplies for Distribution IV. HOSPITALS EXHIBIT 6h V. DEPARTMENTAL STABLES Salaries and Wages Foreman Assistants (not including drivers) Stable Supplies Com Oats Hay 4c * 4c ♦ 4( * Repairs and Betterments VI. CORPORATE STOCK i66 184 r-1907 File No.. Exhibit 7 Perfect Score IOO5C Score Allowed S DEPARTMENT OF HEALTH CITY OF NEW YORK I>airy Inspection Division of Inspections Exhibit 7 — Continued 167 1 Inspection No Time A. P. M. Date 100 2 Tenant P. O. Address — 3 Township County State 4 Owner Party Interviewed _. 5 Milk delivered at Since Formerly delivered at - 6 Creamery on R. R Branch Miles to N. Y 7 Creamery operated by Address 8 Distance of farm from creamery Occupied farm since 9 No. of Cows Breed No. Milking Quarts milk produced 10 All persons in the households of those engaged in producing or handling milk are free from all infectious disease — 11 Date and nature of last case on farm 12 A sample of the water supply on this farm taken for analysis - 190 and found to be - 13 Size of cow barn, length feet. Width feet. Height of ceiling $ Perfect Allow STABLE 14 COW STABLE Is located on elevated jrround with no stagnant water, hog-pen, or privy within 100 feet 15 FLOORS are constructed of concrete or some non-absorbent material 16 Floors are properly graded and water-tight 17 DROPS are constructed of concrete, stone or some non-absorb- ent material 18 Drops are watertight 19 FEEDING TROUGHS, platforms or cribs are well lighted and clean 20 CEILING is constructed cl and is tight and dust proof 21 Ceiling is free from hanging straw, dirt or cobwebs 22 NUMBER OF WINDOWS total square feet which is suttit'ient 23 Window panes are washed and kept clean _ 24 VENTILATION consists of _ which is sufficient 3, fair 1, insufficient© 25 AIR SPACE is cubic feet per cow which is sufficient (600 and over-3) (500 to 600-2) (100 to 500-1) (under 400-O) 26 INTERIOR of stable painted or whitewashed on which is satisfactory 2. fair 1, never O 27 WALLS AND LEDGES are free from dirt, dust, manure or cobwebs 28 FLOORS AND PREMISES are free from dirt, rubbish or decayed animal or vegetable matter 29 COW BEDS are clean 30 LIVE STOCK, other than cows, are excluded from rooms in which milch cows are kept 31 There is direct opening from barn into silo or grain pit 32 BEDDING used is clean, dry and absorbent 33 SEPARATE BUILDING Is provided for cows when sick 34 Separate quarters are provided for cows when calving 35 MANURE is removed daily to at least 200 feet from the bam ( ft.) 36 Manure pile is so located that the cows cannot get at it 1 1 2 2 2 1 2 1 2 1 2 2 1 1 2 1 1 1 1 2 1 (. 3t « 1 1) 37 LIQUID MATTER is absorbed and removed daily and allowed to overflow and saturate ground under or arovmd cow barn 38 RUNNING WATER supply for washing stables is located within building 39 DAIRY RULES of the Department of Health are posted 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 01 62 63 64 65 66 G7 68 69 70 71 72 73 74 75 COW TARD 40 COW TARD Is properly graded and drained. 41 Cow yard is clean, dry and free from manure.... COWS COWS have been examined by Veterinarian ^ Date 190 Report was Cows have been tested by tuberculin, and all tuberculous cows removed Cows are all in good flesh and condition at time of inspection Cows are all free from clinging manure and dirt. (No. dirty ) LONG HAIRS are kept short on belly, flunks, udder and tail UDDER AND TEATS of cows are thoroughly cleaned before milking ALL FEED Is of good quality and all grain and coarse fodders are free from dirt and mould DISTILLERY waste or any substance in a state of fermentation or putrefaction Is fed WATER SUPPLY for cows is unpoUuted and plentiful MILKERS AND MILKING ATTENDANTS are in good physical condition Special Milking Suits are used Clothing of milkers is clean Hands of milkers are washed clean before milking MILKING is done with dry hands FORE MILK or first few streams from each teat is discarded Milk is strained at and in clean atmosphere Milk strainer Is clean _ MILK is cooled to below 50" F. within two hours after milking and kept below 50° F. until delivered to the creamery " Milk from cows within 15 days before or 5 days after parturition is discarded UTENSILS MILK PAILS have all seams soldered flush Milk pails are of the small mouthed design, top opening not exceeding 8 inches in diameter. Diameter Milk pails are rinsed with cold water immediately after using and washed clean with hot water and washing solution Drying racks are provided to expose milk pails to the sun MILK HOUSE MILK HOUSE Is located on elevated ground with no hog-pen, manure pile or privy within 100 feet Milk house has direct communication with _ building Milk house has sufficient light and ventilation Floor is properly graded and water-tight Milk house is free from dirt, rubbish and all material not used in the handling and storage of milk Milk house has running or still supply of pure clean water Ice Is used for cooling milk and is cut from WATER WATER SUPPLY for utensils is from a located feet deep and apparently is pure, wholesome and uncontaminated „ _ Is protected against flood or surface drainage There Is privy or cesspool within 250 feet ( ^ feet) of source of water supply „ _ „ There Is stable, bam-yard, or pile of manure or other source of contamination within 200 feet ( feet) of source of water supply Perfect 1 1 1 2 3 5 2 4 1 2 1 2 1 1 1 1 2 2 1 1 2 1 1 2 2 1 1 1 1 1 1 1 1 5 2 lOU Aixow 1587, 07, 50.000 (P) Insyector of Foods li i68 Exhibit 7 — Continued Exhibit 7 — Continued 169 i| d ► 55 t> tzj >► tz{ Pb g CL g D- g S o 5 » 3 © so QD 1 i > 1 QD B QD • B 1 1 • 1 ! t i ! * • I • 1 i 1 ! _ ? o o o c o o gM jg ^ M M _ P 2 t3 w {3 g a 2 OD g OD g •-» 5 B 5 8- ? I S H !2 H CD H O d H O g H p a o o p & D S' < o O p QD P ■-I CD O (B P' cr o aa 5* ►d* •o ►*• p o cr o P B cr A o a- A ■>► Pi p< A QD OB ■ i I J o p A •I o p o o P P •^ I ! t pi pi CD OD > L P i i S o Si A A P j P J Pi pi QD OB I I o P o i B ^ A •73 I CO o 3 I H « » S3 s n Perfec Score 5 c=oo S » 29 P d A A Pi L I CREAMERY is located on dry and elevated ground 1» at least 100 feet away from any hog-pen, privy-vault, factory, manure loading platform or anything else objectionable Premises surrounding creamery are clean RECEIVING ROOM Is partitioned off from main milk room Air is free from dust, dirt or objectionable odors Weigh vats and storage tanks are....~ covered MILK HANDLING ROOM Is used exclusively for handling milk Xa separate from where cans are washed l^[",",,", separate from where engine or boiler is located - Ig well lighted by windows Has good ventilation - All odors and steam from washing apparatus are carried off WALLS AND CEILING are....„ sheathed and dust tight Are painted with some light colored paint All ledges are clean and free from dust and dirt FLOORS are free from dirt, rubbish or pools of drainage Are made of concrete, stone or some non-absorbent material Are water-tight Are so graded that ali drainage is discharged at one or more points Strainers In floor are at least 12 Inches in diameter ~ SPACE BENEATH CREAMERY is dry jg free from ivaste or rubbish — DRAINS are of earthenware or iron Are water-tight Are continuous from the floor level to point of disposal Are protected against freezing DRAINAGE Is satisfactorily disposed of Discharged into a stream Discharged into a covered cesspool and pipes properly trapped Land disposal at least 500 feet away from creamery PiBrKCT SCOBK , be readily taken apart MILK PUMPS AND PIPES for milk, can Are thoroughly cleaned daily All steam and water pipes are painted and clean STORAGE TANKS OR MIXING VATS are Jn good repair All tin joints are soldered flush Are thoroughly cleaned daily MILK CANS are washed with hot water and washing solution Are rinsed out with clean water Are exposed to live steam for at least two minutes ALL MILK Is protected from dust and dirt while in pools Ig protected while in mixing vats or over aerators Ig received at a temperature not above 60° F Is.«"."..".-..-kept below 50° while held or handled on premises COOLING TANKS are water-tight Are made of some non-absorbent material jiie][,"..... supplied daily with clean water or filled with clean Ice WATER SUPPLY Is ample for all the needs of the creamery Water supply is apparently free from all contamination and Is from __ ___ — ................................ ICE POND is polluted by privy or creamery waste STORAGE TANK for water is cleaned regularly jg covered or protected against dirt ~. ATTENDANTS are cleanly in their habits Garments worn by such employees are clean PRIVY, water closet, earth closet, tight vault Is satisfactorily located Ig in a cleanly condition SPITTING OR SMOKING In any part of the building Is allowed 2 2 1 2 2 1 1 1 2 2 1 2 1 2 2 4 2 2 1 2 1 2 2 2 1 5 1 2 1 1 1 2 2 1 2 1 2 2 2 1 1 1 5 10 2 1 1 2 2 2 1 2 100 AUiOWXD Inspector of Voo<]t lyo Exhibit / — Continued e ■2 ^ -S \ f k fl ^ Z pa iHC^CO"^kOCDt*aOCiO r-l C^ CO »f5 CD \ii BUREAU OF MUNICIPAL RESEARCH HISTORY January ist, 1906 Organized as " Bureau of City Betterment " May 3d, 1907 Incorporated as "Bureau of Municipal Research " PURPOSES To promote efficient and economical municipal government ; to promote the adoption of scientific methods of accounting and of reporting the details of municipal business, with a view to facilitating the work of public officials ; to secure constructive publicity in matters pertaining to municipal problems ; to collect, to classify, to analyze, to correlate, to interpret and to publish facts as to the administration of municipal government. REPORTS, JANUARY, 1906, to AUGUST, 1907 Some Phases of the Work of the Department 0/ Street Cleaning (in print) City Owned Houses Led to the appointment of a commission by the mayor to devise a method of abolishing and preventing the recurrence of unsanitary and illegal conditions found in tenements owned by the city. Salary Increases Not Provided for in Budget Inefficiency of Inspection of Combustibles Led to the dismissal of superintendent. The City of New York, the Street Railroad Companies and a Million and a Half Dollars Led to the establishment of a special bureau in the city's law depart- ment to take up and press the claims of the city against street railroad companies for paving done at the public's expense between the com- panies' rails. How Manhattan is Governed Led to investigation by the commissioners of accounts, upon whose findings the City Club brought charges before Governor Hughes - demanding the removal of Borough President Ahearn. Hearing set for September loth. Analysis of the Salary Expenditure of the Department of Health of the City of Netv York for the Year i gob Led to the adoption of the principle bv the board of aldermen and the board of estimate and apportionment that future budgets should clearly indicate for what specific purposes the money voted is to be expended. Making a Municipal Budget ; Functional Accounts and Records for the Department of Health ( in pri n t ) A Department of Municipal Audit and Examination ; Report on the Office of Commissioners of Accounts Re-organization effected by the commissioner, with the approval of the mayor. \i\MiO r JOT- st^ i It n COLUMBIA UNIVERSITY LIBRARIES 0044241941 ■iji n END OF TITLE