COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD _^ HX64115577 RA643.N48 Hand book of informa HAND BOOK OF THE iiureau of Infectious Diseases 1914 DEPARTMENT OF HEALTH OF THE CITY OF NEW YORK RECAP Co0ege of 3l^l)v^itmn^ anb ^uvQtom Hand Book of Information REGARDING THE ^ - > ROUTINE PROCEDURE OF THE BUREAU OF INFECTIOUS DISEASES 1914 JOHN S. BILLINGS, M. D. Director of Bureau DEPARTMENT OF HEALTH OF THE CITY OF NEW YORK |08 L— 1914 22-520, '14, 2,000 (P) KA H^% TABLE OF CONTENTS Section Page Functions of Bureau ". 1 1 diebctobt of offices^ clinics, liaboeatobiesj Camps, Sanatoria and Maps 2 2 Organization of Staff of the Bureau 3 12 Sanitary Supervision of Infectious Diseases.. 18 Authorization by Sanitary Code — • (a) Requiring Notification by Physicians ... . 4 18 1. Contagious 19 2. Communicable 19 3. Indirectly Communicable 19 (b) Requiring Notification by Institutions. . . 20 1. Communicable 20 2. Parasitic Diseases of the Skin 20 (c) Requiring Reports of Deaths 20 (d) Requiring Notification by Hotels and Lodging Houses 21 (e) Requiring Notification by Laymen 21 (f) Requiring Tuberculosis Reports from In- stitutions 22 (g) Requiring Reports of Removal of Tenants 22 (h) Authorizing Removal to Hospital 23 (i) Prohibiting Removal of Cases 23 (j) Exclusion from School 23 (k) Requiring Isolation Facilities in Insti- tutions 24 (1) Burial Regulations in Infectious Dis- eases 25 (m) Requiring Private Funerals in Infectious Diseases 26 (n) Requiring Burial within 24 hours 26 (o) Requiring Disinfection in Infectious Diseases 27 (p) Authorizing Renovation of Premises.... 27 (q) Requiring Notification of Glanders 27 (r) Requiring Destruction of Glandered Ani- mals 27 (s) Requiring Tagging of Dead Horses 28 (t) Authorizing Destruction of Rabid Ani- mals and Vicious Dogs 28 (u) Forbidding Spitting on Sidewalks, etc.. 29 t Regulations Applying to All Employees — Section Page Temporary Appointments 5 30 Examination of New Employees 6 31 Probation Period 7 31 Forbidding Fees 8 31 Absences from Duties 9 31 Absence with Pay 10 32 Notifications of Absence 11 35 Vacations 12 35 Hours of Duty 13 35 Daily Reports and Time Records 14 36 Completion of Daily Business 15 37 Iiiformation for Public 16 37 Telephone Regulations 17 37 Care of Department Property 18 38 Violation of Sanitary Code 19 39 Smoking 20 39 Knowledge of Regulations 21 40 Regulations Applying to All Officers — Monthly Conferences 22 40 Correspondence and Reports 23 40 Central Filing Bureau 24 41 General Duties 25 42 Special Duties 26 42 (a) Director 42 (b) Chiefs of Division 43 (c) Borough Chiefs 43 (d) Physicians in Charge 44 Regulations Applying to Field Workers — Daily Reports 27 44 Search for New Cases 28 4.5 Badges 29 4r> Personal Attention to Assignments 30 4r) Carfare and Telephone Bills 31 4t» Routine Procedure — Executive Office — Duties of Chief Clerk 32 41 - Reports 33 47 Office of Supplies 34 4£ Records, Blanks, etc. 35 4P Efficiency Ratings 36 4S ii INFECTIOUS DISEASES General Pbocedubb — Section Page Borough Offices 37 51 Notification op Infectious Diseases 38 51 (a) By Private Physicians 51 (b) By Institutions 52 (c) By Death Certificates 52 (d) By Complaints 52 (e) By Nurses, Charity Organizations, etc.. 53 Registration of Infectious Diseases 39 53 Records at Borough Offices 40 53 (a) General Envelope Name- Pile of Active Cases 54 (b) House-File 54 (c) Laboratory File for Diphtheria 55 (d) Laboratory File for Typhoid Fever. ... 55 (e) Card Name-File for Tuberculosis 56 (f) Name-FOes of Terminated Cases 56 (g) Report Postal Address File for Minor Contagious Diseases 56 (h) "Not Found" File for Tuberculosis.... 56 (i) Name-File of Dead Tuberculosis Cases.. 56 Branch Offices 41 56 Branch Office System of Registration 42 57 Records at* Branch Offices 48 57 (a) General Name-File of Contagious Cases. 58 (b) General Date Tally-File of Contagious Cases 58 (c) Envelope Name-File for Tuberculosis... 58 (d) House-File for Tuberculosis 58 (e) Date Tally-File for Tuberculosis 58 (f ) Envelope Name - File for Tuberculosis (Discontinued Cases) 58 General Procedure at Branch Offices 44 58 Tally or "Tickler" Files 45 59 Tally Sheets and Weekly Reports 46 59 Daily Report to Borough Office 47 60 DIVISION OF CONTAGIOUS DISEASES 48 60 Chief of Division 49 61 Chief Diagnostician — Duties 50 61 Borough Diagnostician — Duties 51 61 111 Section Page District Diagnostician — Duties 52 62 (a) District Duty 62 (b) ImmuBization 62 (c) Removal to Hospitals 63 (d) Diagnosis 63 (e) Investigation of Meningitis and Anterior Poliomyelitis 63 (f) Investigation of Absences of Employees. 63 (g) Special School Certificates 63 Instructions for Nurses — On First Visit 53 63 On Revisits 54 65 On Final Visits 55 65 General Instructions for Nurses 56 66 Notification and Registration 57 66 Sanitary Supervision — Inspection of Cases 58 67 Classification of Cases 59 67 (a) Supervision Cases 67 (b) Observation Cases 67 Placarding 60 68 Quarantine 61 68 Charitable Assistance and Education of Pub- lic 62 68 Enforced Removals to Hospital 63 69 Termination of Cases 64 70 Deaths from Infectious Diseases 65 70 A. Procedure in Bureau of Records 7G B. Procedure in Bureau of Infectious Dis- eases 71 C. Duties of Investigator 72 D. Regulations regarding Bodies Removed from City "Not Found" Cases 66 Exclusion from School 67 Permits to Return to School 68 Peocedtjre in the Various Contagious Dis- eases— Section Page Smallpox, Cholera, Plague, Yellow Fever and Typhus Fever 69 74 Management of Smallpox by the Department of Health 70 74 Duties of Diagnosticians, Smallpox 71 75 Cholera, Plague and Yellow Fever 72 77 Typhus Fever 73 77 Diphtheria 74 77 Diphtheria Antitoxin 75 78 Diphtheria Antitoxin in Syringe Containers, — All-Night Stations 76 79 Termination of Cases of Diphtheria 77 79 Diphtheria Carriers 78 80 Scarlet Fever 79 80 Measles 80 80 Social Service, Hospital Convalescents 81 81 Cerebro-Spinal Meningitis 82 82 Acute Poliomyelitis 83 83 MINOR CONTAGIOUS DISEASES— GENERAL PRO- CEDURE German Measles, Mumps, Chickenpox and Whooping Cough 84 84 German Measles 85 84 Mumps 86 84 Chickenpox 87 84 Whooping Cough — Incubation Period and Quarantine 88 85 Whooping Cough — Management 89 85 Other Infectious Diseases — Tetanus, Anthrax, Glanders, Leprosy and Trichinosis 90 86 Malarial Fever, Erysipelas and Pneumonia. . 91 86 Deaths from Malaria 92 86 Erysipelas 93 86 Disinfection 94 87 Requests for Disinfection 95 87 Diseases In which Disinfection is Performed. 96 87 Disinfection of Books 97 88 Section Page Methods op Disinfection 98 89 (a) Paraformaldehyde 90 (b) Liquid Disinfectants 91 Disinfection Tests 99 92 Duties of Disinfectors 100 92 Duties of Disinfectors-in-charge 101 94 Duties of Goods Wagon-Drivers lCn2 95 Ambulance and Wagon Service — Stables ; Disinfecting Plant 103 Ambulance Service 104 Removal of Patients 105 Vehicle Sign 106 Duties of Ambulance Drivers 107 Stables — Duties of Foreman in charge of Stable 108 Duties of Stablemen 109 Wagon Service 110 Disinfection Plants Ill Duties of Disinfector-in-charge 112 Rules for Drivers of Goods- Wagon 113 Express Service of the Department of Health 114 DIVISION OF INSTITUTION INSPECTION— Functions 115 Regulations for the Management of Infectious Diseases in Institutions 116 Isolation 117 Removal to Hospitals 118 Quarantine 119 (a) Hospitals 1. Diphtheria 2. Scarlet Fever 3. Measles 4. Smallpox (b) Institutions 1. Diphtheria 2. Scarlet Fever 3. Measles 4. Smallpox (e) Nurseries and Day Camps Chief of Division 120 vi Division of Institution Inspection — (Continued) Skction Page Supervision of Institutions 121 107 Notification 122 10*8 Registration 123 109 Office of Division of Institution Inspection. .124 109 Assignment of Cases 125 110 Duties of Institution Inspectors 126 110 DIVISION OF TUBERCULOSIS 127 113 Organization 128 113 (a) Chief of Division 113 (b) Borough Offices 113 (c) Branch Offices 113 (d) Clinics and Clinic Districts 114 (e) Clinic Auxiliaries 114 (f) Local Clinic Relief Committees 114 (g) Tuberculosis Hospital Admission Bu- reau 114 (h) Tuberculosis Day Camps 114 Notification and Registration 129 114 Procedure at Branch Office 130 115 Current Record File 131 115 General Routine 132 IIG Monthly Census 133 117 Report to Hospital Admission Bureau 134 117 Classification of Cases 135 118 Class I. Cases Under the Care of Pri- vate Physicians 136 118 Class II. A. Cases Reported by non-De- partment Tuberculosis Clin- ics in their Own District. . .137 119 B. Cases Attending Other Clin- ics 120 Class III. Cases Admitted to Hospital. . .138 120 Class IV. Cases Leaving City Tempo- rarily — Entering Sanatoria. 139 121 Class V. Cases not Found at Address Given 140 121 Class VL "At Home" Cases 141 122 Dead Cases 142 122 Recovered Cases 143 123 Cases Leaving the City Permanently 144 124 vii Division of Tuberculosis — (Continued) — ■ Section Page Undiagnosed Clinic Cases 145 124 Scliool Children 146 124 Cases Reported as Living in Other Boroughs. 147 125 Suspected Cases and Complaints 148 126 Investigation of Suspected Cases and Com- plaints 149 127 Recommendation for Charitable Aid 150 127 Recommendation for Hospital Care 151 128 Supervision of Families of Cases in Hospital. 152 128 Sanitary Supervision of Tuberculosis — Disinfection 153 128 Kinds of Disinfection Ordered 154 128 Renovation 155 129 Scrubbing of Floors and Woodwork 156 130 Placards 157 131 Voluntary Renovation 158 131 Cleaners and Scrubwomen 159 132 Forcible Removal of Cases of Pulmonary Tuberculosis 160 132 Supervision of Cases at Their Homes — General Procedure 161 133 Circulars of Instruction 162 134 Description of Nurses' Work in Homes 163 135 Duties of District Nurses in Clinics 164 136 History Cards 165 136 District Work of Clinic Physicians 166 137 Tuberculous Children 167 137 Visits to Lodging House Patients 168 138 Visits to Clinic Patients 169 138 Recovered Cases 170 138 Information for the Public Regarding Super- vision OF Tuberculosis (Circulars^ 171 139 Moving Picture and Stereopticon Exhibitions. 172 140 Care of Department's Tuberculosis Patients — The Tuberculosis Hospital Admission Bureau. 173 140 Institutions Admitting Through Bureau 174 141 Applications for Admission 175 142 System of Registration 176 142 Examination at Admission Bureau 177 143 Visits by Physicians for Diagnosis 178 143 viil Care of Department's Tuberculosis Patients — (Continued) — • Section Page Investigation of Home and Financial Condi- tions 179 143 Admission to Hospital 180 144 Home Conditions after Admission 181 144 Supervision of Family While Patient is in Hospital 182 145 Reports from Institutions Regarding Their Patients 183 145 Home Conditions of Riverside Cases 184 145 Sanatorium Applicants 185 146 Bureau of Information 186 147 Tuberculosis Preventorium for Children, Farmingdale, N. J 187 147 Tuberculosis Institutions Maintained by the Department of Health — Riverside Hospital 188 150 Otisville Sanatorium 189 150 Instructions for Applicants 190 151 Tuberculosis Camps and Fresh Air Schools.. 191 152 A. The Middletown 152 B. The Rutherford 152 Routine Procedure 192 152 Tuberculosis Camp Nurses 193 153 Tuberculosis Camp Regulations 194 153 Tuberculosis Clinics 195 157 Objects of Establishment 196 157 Clinic Staff 197 158 Physician-in-charge of Clinic 198 159 Organization 199 159 Furniture, Signs, Maps, etc 200 160 Forwarding of Reports 201 161 Daily Reports to and from the Branch Office. 202 161 Reports to Headquarters 203 162 Tabulation of Statistics 204 162 Routine Procedure 205 162 Instructions for History Taking 206 163 System of Filing Histories 207 167 Applicants Living in other Clinic Districts. .208 168 Non-Tuberculous Applicants 209 168 Examination of Bakers 210 168 iz TuBBECDLosis CLINICS — (Continued) — Section Paqb Examination of Applicants for Peddlers' License 211 (a) To peddle (b) To maintain stands — fruits, etc. . . . (c) To maintain stands — ^newspapers. . . (d) To maintain stands — hackdrivers. . . (e) Porters Recommendations for Hospital Care 212 Sputum and Urine Specimens 213 Reporting of New Cases 214 Deaths 215 Procedure In Examination Rooms 216 System of Abbreviations 217 Confirmatory Re-Examinations 218 Instructions of Patients (Circular) 219 Medicines 220 Throat Examinations 221 Home Visits by Nurses 222 Delinquent Cases 223 Study of Cases 224 Final Diagnosis — Later Examinations 225 Charitable Aid 226 Clinic Relief Committees 227 Home Visits by Clinic Physicians 228 Milk and Eggs 229 Rules for Attending Physicians 230 Volunteer Attending Physicians 231 Appointment and Promotion of Volunteer At- tending Physicians 232 Clinic Nurses 233 Rules for Clinic Nurses 234 Circular of Information 235 The Women's Auxiliary to the Tuberculosis Clinics of the Department of Health 236 The Association of Tuberculosis Clinics 237 DIVISION OF TYPHOID FEVER 238 Chief of Division 239 Office of Chief of Division 240 Typhoid Charts and Tabulations 241 Mapping of Cases 242 X Division of Typhoid Fevbe — (Continued)— Section Page Typhoid Fever Notification and Registration — Borougli Office 243 187 Brancli Offices 244 188 Investigation of Milk Stores 245 189 Investigation of Cases by Typhoid In- spectors 246 189 Antityphoid Immunization 247 191 Special Instructions for Typhoid Inspectors. .248 192 Disinfection 249 193 Quarantine 250 193 DIVISION OF NURSING— Superintendent of Nurses 251 194 Supervising Nurses 252 194 Registration and Clinic Nurses 253 195 District Nurses 254 195 District Nurses' Outfit 255 196 General Duties of District Nurses 256 197 Nurses' Daily Report 257 197 Nurses' Weekly Record 258 198 DIVISION OF VENEREAL AND VETERINARY DISEASES 259 198 Chief of Division 260 198 Venereal Diseases 261 199 Registration 262 199 Inspection of Cases 263 200 Medical Adviser 264 200 Diagnostic Clinics for Venereal Diseases 265 201 Serological Laboratory 266 202 Wassermann Test for Syphilis 267 203 Interpretation of the Wassermann Readings. 268 204 Gonorrhoea-Complement Fixation Test 269 204 Smear Examination for Presence of Gono- coccl 270 205 Symbols Used in Reporting Results of Ex- amination of Gonococcus Smears 271 205 Treponema Pallidum Examination 272 205 Advertising Venereal Quacks 273 206 Circulars of Information 274 206 zl Section Page Glanders 275 207 General Procedure — ■ Notification 276 Registration 277 Investigation 278 Disinfection of Stables after Glanders 279 Rabies — General Procedure 280 Notification and Registration 281 Investigation 282 Clinics for Administration of Anti-Rabic Treatment 283 DIAGNOSIS LABORATORY— Scope of Work 284 Hours of Examination 285 Routine Procedure 286 Duties of the Assistant Director 287 Circulars of Information 288 Diphtheria — Outfits for Obtaining Cultures 289 Preparation and Examination of Cultures . . . 290 Abbreviations of Results 291 Test for Virulence 292 Sterilization of Cultures and Storage of Slides 298 Recording and Reporting of Results 294 Culture Lists 295 Routine Procedure In Borough Offices 296 Cultures from School Children 297 Cultures from Department Hospitals 298 Examinations on Sundays and Holidays .... 299 Preparation of Diphtheria Culture Media... 300 Circular of Information 301 Tuberculosis, Typhoid (Widal, Diazo), Ma- laria, Meningitis — General Procedure 302 Tuberculosi s — Sputum Outfits 303 Method of Preparation, Examination and Re- porting 304 Antiformin Method 305 Reports 306 zU Typhoid Fbvee — Section Page Widal Reaction Outfit 307 226 TechnJc of Examination 308 226 Ehrlich's Diazo Reaction Outfit 309 227 Technic of Examination 310 227 Circular of Information 311 227 Examination for Malarial Organisms 312 228 Cbrebro-Spinal Meningitis 313 228 Collection of Specimens and Supervision of Supply Stations — Supply Stations 314 229 Stock of Supplies Carried by Stations 315 230 Duties of Collectors 316 231 General Rules of Diagnosis Laboratory 317 233 Collection Routes — Manhattan 318 235 Collection Routes — ^Bronx 319 239 Collection Routes — ^Broolslyn 320 240 Collection Routes — Queens 321 244 Collection Routes — Richmond 322 246 LIST OF PUBLICATIONS, BLANK FORMS, ETC.323 247 Forms of Other Bureaus Also Used in the Bureau 324 262 INDEX 263 ziU HAND BOOK OF INFORMATION REGARD- ING THE ROUTINE PROCEDURE OF THE BUREAU OF INFECTIOUS DISEASES OF THE DEPARTMENT OF HEALTH, CITY OF NEW YORK FUNCTIONS OF BUREAU. Sec. 1. Tlie Bureau of Infectious Diseases exer- nses the following functions throughout the Greater I)ity of New York: — i 1. The general sanitary supervision of all infec- |ious diseases, including: A. The acute contagious diseases (Scarlet Fever, Diphtheria, Measles, etc.) together with the disin- ection of goods and premises, the removal of patients Department Hospitals, immunization against Diph- heria and conducts Whooping Cough Camps and Jlinics. B. Tuberculosis, conducting Tuberculosis Hospital admission Bureau, the Tuberculosis Clinics and the 'oat Camps. '''. Typhoid Fever, with the performance of immu- ization against that disease, Cerebro-spinal Menin- gitis, Acute Poliomyelitis, Malarial Fever, and other communicable diseases. D. The Venereal and Animal diseases, Glanders, and Rabies, conducting the Serological Laboratory, the Wassermann Clinics, and the Clinics for the Pasteur treatment of Rabies. ii. The Bureau also conducts the Diagnosis Lab- oratory, the work of which comprises: (a) diagnostic examinations of specimens submitted by physicians; (b) the preparation of diagnostic outfits, and (e) col- lection of specimens and supervision of supply stations in all Boroughs. DIRECTORY OF OFFICES, CLINICS, LABORA- TORIES. ETC. Sec. 2. The offices of the Bureau of Infectious Dis- eases are located as follows: EXECUTIVE OFFICES, Centre and Walker Streets, Tel. 6280 Franklin. BOROUGH OFFICES. MANHATTAN Main Borough Office, Centre and Walker Sts.,— Tel. 6280 Franklin. BRONX Main Borough Office, 3731 Third Ave.,— Tel. 1975 Tremont. BROOKLYN Main Borough Office, Flatbush Ave. and Willoughby St.,— Tel. 4720 Main. | QUEENS Main Borough Office, 374 Fulton St., Jamaica, — ^Tel. 1200 Jamaica. RICHMOND Main Borough Office, Bay Street, Stapleton, — ^Tel. 440 Tompkiusvllle. II BRANCH OFFICES. MANHATTAN— BRANCH OFFICES : 331 Broome St.— Tel, 8859 and 7914 Orchard. Ill E. 10th St.— Tel. 2859 and 8144 Orchard. 229 E. 57th St.— Tel. 1637 and 2526 Plaza. 420 E. 116th St.— Tel. 2375 and 828 Harlem. 2228 Broadway— Tel. 4408 Schuyler. 307 W. 33rd St.— Tel. 3471 and 1394 Greeley. 22 Vandam St.— Tel. 412 Spring. BRONX— BRANCH OFFICE: 493 East 139th St.— Tel. 5702 Melrose. BROOKLYN— BRANCH OFFICES : 306 South 5th St.— Tel. 886 and 1293 Williamsburg. 60th St. and 2nd Ave.— Tel. 2434 and 3988 Sunset. 64 Penna. Ave.- Tel. 2732 East New York. 55 Sumner Ave. — Tel. 3228 Williamsburg. 794 West St.— Tel. 1867 and 1866 Bath Beach. QUEENS— BRANCH OFFICE: 110 Broadway, Flushing— Tel. 731 Flushing. STABLES AND DISINFECTING STATIONS. MANHATTAN, Ft. East 16th St.— Tel. 1600 Stuy- i^esant. BRONX, Ft. East 132nd St.— Tel. 4000 Melrose. BROOKLYN, Kingston Ave. & Fenimore St.— Tel. WOO Flatbush. QUEENS, Haake Farm— Tel. 1200 Jamaica. RICHMOND, Castleton Corners— Tel. 3.52 New Dorp. 3 TUBERCULOSIS CAMPS. MANHATTAN, Day Camp Ferryboat "Middle- to^Yn," Ft. of E. 91st St.— Tel. 2957 Lenox. BROOKLYN, Day Camp Ferryboat "Rutherford," Ft. of Fulton St.— Tel. 1530 Main. LABORATORIES. DIAGNOSIS LABORATORY, Centre & Walker Sts.,— Tel. 6280 Franklin. SEROLOGICAL LABORATORY, Centre & Walker Sts.,— Tel. 6280 Franklin. TUBERCULOSIS CLINICS. All applicants for diagnosis, advice, or treatment are referred to the tuberculosis clinic of the district in which they live. [Note. — All Department of Health Clinics have children's classes from 10 A. M. to noon every Satur- day.] MANHATTAN. 8t. Luke's Hospital Dispensary, 113th Street and Amsterdam Avenue. — Monday, Tuesday, Thursday and Friday, 2 to 4 P. M. Harlem Hospital Dispensary, 136th Street and Lenox Avenue. — Week days, 1 to 3 P. M. ; Thursday, 7 to 8 P. M. Children, Tuesday and Saturday, 3 to 5 P. M. Vanderhilt Clinic, 60th Street and Amsterdam Ave- nue. — Daily, 1 to 2.30 P. M. Monday, Wednesday and Friday, 9 to 10.30 A. M. Children, Saturday, 2 P. M. Department of Health, Lower West Side Clinic, 307 1 West 33d Street— Week days, 2 to 4 P. M.; Thurs- day, 8 to 9 P. M. Children, Saturday, 10 A. M. to I 12 M. , New York Hospital, Out Patient Department, 8 West 16th Street.— Monday and Friday, 2 to 3 P. M. ; Tues- I day and Thursday, 7 to 9 P. M. Children, Wednesday, 3 P. M. and Saturday, 12 M. St. Vincenfs Hospital Dispensary, 149 West 11th I Street. — Tuesday, Thursday and Saturday, 10 to 11 ! A. M. Department of Health, Southern Italian, 22 Van- I dam Street. — Week days, 2 to 4 P. M. ; Thursday, 8 to 9 P. M. Children, Saturday, 10 A. M. to 12 M. A special guide card is issued (Form 37 L). New YorJc Dispensary, 34-36 Spring Street. — Week days, 11 A. M. to 12.30 P. M. Gouverneur Hospital Dispensary, foot of Gouver- neur Street. — Monday, Wednesday, Friday, 2 to 4 P. M. ; Tuesday, Thursday, Saturday, 4 to 6 P. M. ; Wednesday, 8 to 9 P. M. Children, Monday, Wednes- day and Friday, 2 to 4 P. M. Department of Health, Corlears Clinic, 331 Broome Street— Week days, 2.30 to 4.30 P. M. ; Thursday, 8 to 9 P. M. Children, Saturday, 10 A. M. to 12 M. Department of Health, Lower East Side Clinic, 111 East 10th Street.— Week days, 2 to 4 P. M. ; Tuesday, Thursday and Saturday, 10 A. M. to 12 M. ; Thurs- day, 8 to 9 P. M. Children, Saturday, 10 A. M. to 12 M. Bellevue Hospital, Out Patient Department, 419 East 26th Street.— Week days, 1.30 to 3.30 P. M. Children, Tuesday and Saturday, 1.30 to 3.30 P. M.; Friday, 7 to 9 P. M. Department of Health, Middle East Side Clinic, 231 East 57th Street.— Daily, 2 to 4 P. M. Presbyterian Hospital Dispensary, 70th Street and Madison Avenue. — Week days, 1.30 to 3 P. M. German Hospital Dispensary, 76th Street and Park Avenue. — Monday, Wednesday, Thursday and Satur- day, 11 A. M. to 12 M. Mt, Sinai Hospital Dispensary, 100th Street and Madison Avenue. — Week days, 10 to 11 A. M. Department of Healthy Harlem Italian Clinic, 420 East 116th Street.— Week days, 10 A. M. to 12 M.; Tuesday, Thursday and Saturday, 2 to 4 P. M. ; Tues- day, 8 to 9 P. M. Children, Saturday, 10 A. M. to 12 M. Flower Hospital Dispensary, Eastern Boulevard and 63rd Street— Wednesday, 2.30 to 3.30 P. M. THE BRONX. Department of Health, Northern Clinic, Third Av( nue and St. Paul's Place. — Week days, 2 to 4 P. M.;' Thursday, 8 to 9 P. M. Children, Saturday, 10 A. M. to 12 M. Department of Health, Southern Clinic, 493 East 139th Street.— Week days, 10 A. M. to 12 M. ; Tuesday, 8 to 9 P. M. Children, Saturday, 10 A. M. to 12 M. 6 BROOKLYN. Department of Health, Eastern District Clinic, 306 South 5th Street.— Daily, 2 to 4 P. M. Children, Sat- urday, 10 A. M. to 12 M. Department of Health, Germantown Clinic, 55 Sum- ner Avenue. — Daily, 2 to 4 P. M. Children, Saturday, 10 A. M. to 12 M. Department of Health, Brownsville Clinic, 64 Penn- sylvania Avenue. — Week days, 2 to 4 P. M. Children, Saturday, 10 A. M. to 12 M. Department of Health, Bay Ridge Clinic, 60th Street and 2d Avenue. — Monday, Wednesday, Friday, 2 to 3 P. M. Department of Health, Main Clinic, Fleet and Wil- loughby Streets. — Week days, 2 to 4 P. M. Night clinics for the whole of Brooklyn, Tuesday and Thursday, 8 to 9 P. M. Children, Saturday, 10 A. M. to 12 M. Department of Health, ParJcville Clinic, 974 West Street.— Daily, 2 to 4 P. M. Children, Saturday, 10 A. M. to 12 M. QUEENS. Department of Health, Flushing Clinic, 212 Broad- way, Flushing. — Daily, 2 to 4 P. M. Department of Health Clinic, 10 Union Avenue, Jamaica.— Daily, 2 to 4 P. M. Children, Saturday, 10 A. M. to 12 M. RICHMOND. Department of Health Clinic, Bay Street, Staple- ton.— Tuesday, Thursday, Saturday, 2 to 4 P. M. TUBERCULOSIS HOSPITAL ADMISSION BUREAU. Maintained by tlie Department of Health, the De- partment of Public Charities and Bellevue and Allied Hospitals, 426 First Avenue. Telephone 8667 Madison Square. Hours: 9 A. M. to 5 P. M. TUBERCULOSIS HOSPITALS AND SANATORIA. Ray Brook, New York State Institution, located in the Adirondacks ; incipient cases only. Otisville Sanatorium of the Department of Health, located in Orange County; favorable cases only (first or early second stage). These patients are sent to Riverside for observation before being admitted. Bedford Hills Sanatorium, Westchester County, par- ticularly for Hebrews desiring Kosher food; must be residents of New York City. Seaview Hospital, Department of Charities, located on Staten Island; favorable cases desired. Cases un- desirable at Otisville, accepted at Seaview. Riverside Hospital of the Department of Health, lo- cated on North Brother Island; principally used for detention cases; separate reception pavilions for Otis- ville patients under observation and awaiting admis- sion. Metropolitan Hospital of the Department of Chari- ties, Blackwell's Island; advanced cases. 8 Seton Hospital, Spuyten Duyvil. St. Joseph's Hospital, Brook Avenue and 143rd Street, The Bronx. St. Vincent's Hospital, Staten Island. St. Peter's Hospital, Henry Street, Brookljm. Brooklyn Home for Consumptives, 240 Kingston Avenue, Brooklyn. DIAGNOSIS CLINICS FOR VENEREAL DISEASES. Manhattan — Centre and Walker Streets. Week days, 9 to 10 A. M.; 307 West 33rd Street, Wednesdays, 8 to 9 P. M. Brooklyn — 29 Third Avenue. Week days, 9 to 11 A. M. ; Tuesdays and Fridays, 8 to 9 p. m. CLINICS FOR PASTEUR TREATMENT OF RABIES. Manhattan — Centre and Walker Streets. Week days, 1 to 4 P. M. Brooklyn — 29 Third Avenue. Week days, 11 A. M. to 2 P. M. The Bronx — ^Third Avenue and St. Paul's Place. Week days, 11 A. M. to 1 P. M. Queens — Cases attend Brooklyn Clinic. Richmond — Cases attend Manhattan Clinic. Sundays and Holidays — Cases from all Boroughs at- tend Brooklyn Clinic: 10 A. M. to 12 M. 9 Map of Manhattan and The Beonx, showing Tu- BEECTJLOSIS ClINIC DISTEICTS. HEILTH OEPi'!TKtNT B>ION« NORTKEIIN CLINIC MEilTH OE^iRTHEHT BRCNXSOUTHCRM CLINIC 10 I IMap of Brooklyn and Queens, showing Tubeecu- Losis Clinic Distbicts. FLUSHING JjOfFM AN '^ ^■^ 1 ^BOULEVARD '^ mnomcREijc/ VILLE dp^ .«^- JAMAICA 2 aV MAIN "% S PARKVILLE ;S^i>^ 6 ISY^^ 11 Sec. 3. Chart showing Organization of Bureau. BUREAU OF INFECTIOUS DISEASES Chief Clerk Clerk in Charge of SuppheB DIRECTOR ASSISTANT TO DIRECTOR Executive Office Clerk in Charge of Employes' Records Clerks DIVISIONS Stenographers Helpers Tuberculosis. Cliief of Division Sopeivisor of Clinics Admission Bureau -in-Charge Inspectors Supervising Nurse Nurses Clerks Stenographer Cleaners Contagious Diseases. Chief of Division Chief Diagnostician Physician-in-Oharge of Am- bulances and Stables Supervising Automobile En- gineman Clerk Stenographer Typhoid Fever. Chief of Division Chief Clerk Medical Inspec- tors Clerks Stenographer Venereal and Veterinary. Chief of Division Chief Veterinarian Veterinarians Medical Adviser Medical Inspectors Hospital Physician Nurses Chief Clerk Clerks Stenographer Bacteriologist-in-Charge of Serological Laboratory Laboratory Assistants Laborers Cleaners Institution Inspection. Nurses. Chief of Division Medical Inspec- tors Clerk Superintendent Assistant Super- intendent Clerk Diagnosis Laboratory. Assistant Director Bacteriological Diagnosti- cian in Charge of Labora- tory Bacteriological Diagnosti- cians Laboratory Assistants Clerks Laborers Helpers BOROUGH OFFICES Manhattan. The Bronx. Borough Chief Borough Diagnostician Chief Clerk Clerks Stenographers Disinfector-in-Charge Disinfectors J'oreman in Charge of Stable Drivers AjUtomobile Enginemen "ismfector-in-Charge of Disinfecting oration Borough Chief Borough Diagnostician Chief Clerk Clerks Stenographers Disinfector-in-Charge Disinfectors Foreman in Charge of Stable Drivers Stablemen Automobile Enginemen Borough Chief Borough Diagnostician Chief Clerk Clerks Stenographers Disinfector-in-Charge Disinfectors Foreman in Charge of Stable Drivers Stablemen Automobile Enginemen _ Disinfector-in-Charge of Dism- fecting Station Borough Chief Chief Clerk Clerks Stenographer Disinfeetor-in-Charge Disinfectors Foreman in Charge of Stable Drivers Stablemen Borough Chief Clerk Drivers Laborers Disinfectors Physicians in Charge District Diagnosticians aupervising Nurses Nurses Branch Offices and Clinics Attending and Assistant Attending Physicians Volunteer Attending Physicians Clerks Cleaners Day Camps Physicians in Charge nfplfniS Supervising Nurses ?JSmen Domestics SANITARY SUPERVISION OF INFECTIOUS DISEASES. AUTHORIZATION BY SANITARY CODE. Sec. 4. Previous to May 6, 1913, the supervision exercised by the Department of Health over diph- theria, measles, scarlet fever and other diseases actively contagious, was conducted through inde- pendent Divisions of Contagious Diseases, one in each Borough. As the work done by these divisions was similar in character to that performed by the Di- vision of Communicable Diseases, the Board of Health at a meeting held May 6, 1913, adopted a resolution combining the two, thus creating a new division to be known as the Division of Infectious Diseases. The Section of Contagious Diseases continued the work of the former divisions. By resolution of the Board of Health adopted October 28, 1913, the Division of Infectious Diseases was raised to the rank of a Bureau, and its former Sections to the rank of Divis- ions. The Bureau of Infectious Diseases of the Depart- ment of Health exercises sanitary supervision over all infectious diseases (for detailed list, see Articles 1, 2 and 3 below) occurring in the City of New York, by virtue of the following sections of the Sanitary Code: REQUIRING NOTIFICATION BY PHYSICIANS. (a) It shall be the duty of every physician to re- port to the Department of Health, in writing, the full name, age and address of every person suffering from any one of the infectious diseases included in 18 Llie list appended, with the name of the disease, within :wenty-four hours of the time when the case is first seen: 1. — Contagious (very readily communicable) ; Meas- es, rubella (rotheln), scarlet fever, small-pox, vari- cella (chicken-pox), typhus fever, relapsing fever. 2. — Communicable: Diphtheria (croup), typhoid 'ever, Asiatic cholera, tuberculosis (of any organ), plague, tetanus, anthrax, glanders, epidemic cerebro- jpinal meningitis, leprosy, infectious diseases of the 3ye (trachoma, suppurative conjunctivitis), puerperal septicaemia, erysipelas, whooping cough, acute ante- ior poliomyelitis (infantile paralysis). 3. — Indirectly Communica'ble (through intermediary lost) : Yellow fever, malarial fever. [Note. — In this provisional classification of the In- fectious diseases, arranged for practical purposes, the aaost readily communicable of these diseases, embrac- ing the exanthemata and typhus fever, have been placed in a group by themselves and called contagious. This has been done with a view to emphasizing a dis- tinction, which is not only of scientific significance, i3ut of practical importance, in dealing with the sani- tary features of administration. This distinction is furthermore of importance because it avoids the mis- anderstandlng and alarm frequently caused by in- luding In the same class the very readily communi- able diseases (such as small-pox), and the much less ommunicable diseases (such aa tuberculosis), which require very different sanitary measures for their 2ontrol.] 19 REQUIRING NOTIFICATION BY INSTITUTIONS (b) It sliall be the duty of the commissioners oi managers or the principal, superintendent, or physi- cian of each and every hospital, public institution oij dispensary, in this city, to report to the Department! of Health, in writing, the full name, age and address. of any person suffering from any one of the infec- tious diseases included in the list appended, with the name of the disease, within twenty-four hours of the time when the case is first seen : A. — Communicahle: Typhoid fever, influenza, lobar pneumonia, broncho-pneumonia, infectious diseases ol the gastrointestinal canal (dysentery, cholera morbus, cholera infantum, summer diarrhoeas of infants). B. — Parasitic Diseases of the 8km: Scabies, tinea tonsurans, impetigo (contagious), favus. [Note. — In this list of diseases reporting is required by the Department of Health in order that data may be obtained for general and special investigation of the modes and sources of infection and as to the prev- alence and distribution of these diseases. The De- partment of Health does not purpose to exercise a sanitary surveillance in these cases, but desires in- formation with a view to the ultimate removal or im- provement in the conditions which now foster them. Notification is required in certain of these diseases because of the liability to their extension among the children in schools.] REQUIRING REPORTS OF DEATHS. (c) It shall be the duty of every physician to re- port forthwith, in writing, to the Department of Health, the death of every person who dies from, or 20 while suffering with, any infectious disease, and to state in such report the specific name and type of such disease. REQUIRING NOTIFICATION BY HOTELS AND LODGING HOUSES. (d) It shall be the duty of every keeper of any boarding house or lodging house, and the proprietor of every lodging house or hotel, to report forthwith to the Department of Health all the known facts in regard to any person ill, in any house or hotel under his or her charge, and suffering from any one of the following infectious diseases : measles, diphtheria (croup), scarlet fever, small-pox, chicken-pox, epi- demic cholera, typhus fever, rubella (rotheln), plague, tuberculosis and whooping cough. REQUIRING NOTIFICATION BY LAYMEN. (e) It shall be the duty of every person having knowledge of the existence of any person afflicted with any one of the following infectious diseases : measles, diphtheria (croup), scarlet fever, small-pox, chicken- pox, epidemic cholera, typhus fever, rubella (rotheln), plague, tuberculosis, typhoid fever and whooping cough, who he has reason to think requires the atten- tion of the Department of Health, to at once report to the Department all facts in regard to the disease; and no person shall interfere with or obstruct the en- trance, inspection or examination of any building or house, or the occupants thereof, by the inspectors and officers of this Department, when any case of Dne of the infectious diseases above specified has been rejtorted as existing in such house or dwelling; nor shall any person interfere with or obstruct, mutilate 21 or tear down any notices of this Department posted in or on any premises in the City of New York. REQUIRING TUBERCULOSIS REPORTS FROM INSTITUTIONS. (f) It shall be the duty of the commissioners or managers, or the principal, superintendent or physi- cian of each and every public or private institution or dispensary in this city to report to the Department of Health, in writing, — or to cause such report to be made by some proper and competent person, — the name, age, sex, occupation and latest address of every per-; son afflicted with tuberculosis, who is in their care or who has come under their observation, within one week of such time. It shall be the duty of every person sick with this disease and of every person in attendance upon any one sick with this disease, and of the authorities of public and private institutions j or dispensaries, to observe and enforce all the sani- tary rules and regulations of the Board of Health for preventing the spread of pulmonary tuberculosis. REQUIRING REPORTS OF REMOVAL OF TENANTS. (g) Every owner, lessee, tenant and occupant of any dwelling or apartment in the City of New York shall forthwith report to the Department of Health in writing the removal of any person from such dwelling or apartment who shall be suffering from any of the following infectious diseases: measles, diph- theria (croup), scarlet fever, small-pox, chicken-pox, epidemic cholera, typhus fever, rubella (rotheln), plague, whooping cough or tuberculosis (of any or- gan). 22 AUTHORIZING REMOVAL TO HOSPITAL. (h) Whenever an Inspector of this Department shall report in writing that any person is sick of any infectious disease, nnder such circumstances that the continuance of such sick person in the place where he or she may be is dangerous to the lives of other per- sons residing in the neighborhood, the Sanitary Su- perintendent, an Assistant Sanitary Superintendent, or the Chief Inspector of the Division of Contagious Diseases, upon the report of the ^Medical Inspector of the Department, may cause the removal of such sick person to one of the hospitals under the charge of this Department or to a Hospital delegated by the Board lof Health. PROHIBITING REMOVAL OF CASES, (i) No person shall within this city, without a '[permit from the Board of Health, carry, remove, or cause or permit to be carried or removed, any per- 'son sick with any infectious disease, or remove or cause to be removed, any such person from any build- ing or vessel to any other building or vessel or to the shore, or to or from any vehicle in any part of the city. Nor shall any person, by any exposure of any individual sick of any infectious disease, or of the ' body of such person, or by any negligent act con- ^ nected therewith, or in respect of the care or cus- " tody thereof, or by a needless exposure of himself, ^ ?ause or contribute to, or promote the spread of dis- '' ?ase from any such person, or from any dead body. EXCLUSION FROM SCHOOL. 0) No principal or superintendent of any school, ind no parent, master or custodian of any child or 23 minor (having tbe power and authority to prevent) shall permit any child or minor having scarlet fever diphtheria (croup), small-pox or any dangerous, in fectious or contagious disease, or any child in any family in which any such disease exists or has re- cently existed, to attend any public or private school until the Board of Health shall have given its per- mission therefor, nor in any manner to be unneces- sarily exposed, or to needlessly expose any other person to the taking or to the infection of any con- tagious disease. REQUIRING ISOLATION FACILITIES IN INSTI- TUTIONS. (k) In every sanatorium, sanitarium, day nursery, convalescent home, home for children, reformatory, training school, boarding school, hospital, and dispen sary, or institution for the care or treatment of persons in the City of New York there shall be provided and maintained a suitable room or rooms for the temporary isolation of persons suffering from any one of the fol- lowing infectious diseases : Measles, diphtheria (croup), scarlet fever, small-pox, chicken-pox, epi- demic cholera, typhus fever, rubella (rotheln), plague and whooping cough, and such persons shall imme- diately be separated from other persons at such dis- pensary or hospital. It shall be the duty of the physi- cian or physicians, and of the officers and managers of every hospital or dispensary, to cause a report to be immediately made to the Department of Health of the City of New York of every person afflicted with any one of the infectious diseases herein specified who comes to their knowledge, and to have such persons 24 properly isolated from other persons; and shall also immediately report or cause to be reported to the said Department the name, age (so far as can be ascer- tained) and residence of every person received or treated thereat who is afflicted with puerperal septi- caemia or suppurative conjunctivitis and the name of the particular disease with which the person is so afflicted; and shall also report the name and address of the physician or midwife in attendance at the time of the onset of the disease, which information it is hereby made the duty of such hospital or dispensary to obtain and record among its records. BURIAL REGULATIONS IN INFECTIOUS DISEASES. (1) It shall be the duty of every undertaker hav- ing notice of the death of any person within the City of New York of small-pox, diphtheria (croup), scarlet fever, yellow fever, typhus fever, plague, Asiatic cholera, measles, cerebro-spinal meningitis, acute poliomyelitis, or any other infectious disease dangerous to the general health of the community, or of the bringing of the dead body of any person who has died of any such disease into such city, to give mmediate notice thereof to this Department. No per* son shall retain or expose, or assist in the retention 9r exposure of the dead body of any such person xcept in a coffin or casket properly sealed; nor shall lie allow any such body to be placed in any coffin or casket unless the body has been wrapped in a sheet iaturated with a proper disinfecting solution and he coffin or casket shall then be immediately and per- manently sealed. No undertaker shall assist in the public or church funeral of any such person. No 25 undertaker shall use, or cause or allow to be used, at any funeral, or in any room where the dead body of any person shall be, any draperies, decorations, rugs or carpets, belonging to or furnished by him or under his direction. REQUIRING PRIVATE FUNERALS IN INFEC- TIOUS DISEASES. (m) A public or church funeral shall not be held of any person who has died of small-pox, diphtheria (croup), scarlet fever, cerebro-spinal meningitis, acute poliomyelitis, yellow fever, typhus fever, Asiatic cholera, measles or plague ; but the funeral of such person shall be private, and it shall not be lawful to invite, or permit at the funeral of any person who has died of any one of the above diseases, or of any infec- tious disease, or at any services connected therewith, any person whose attendance is not necessary, or to whom there is danger of contagion thereby. REQUIRING BURIAL WITHIN 24 HOURS. (n) No person shall ahow to be retained unburied the dead body of any human being for a longer time than four days, or where death has resulted from small-pox, diphtheria (croup), scarlet fever, cerebro- spinal meningitis, acute poliomyelitis, yellow fever, typhus fever, plague, Asiatic cholera or measles, for a longer time than twenty-four hours, after death of such person, without a permit from the Sanitary Superintendent or an Assistant Sanitary Superintend ent, which i)ermit shall specify the length of time during which such body may be retained unburied. 2G REQUIRING DISINFECTION IN INFECTIOUS DISEASES. (o) Adequate disinfection or cleansing and renova- tion of premises, furniture and belongings, deemed by the Department of Health to be infected by con- t.-igious or communicable diseases, shall immediately follow the recovery, death or removal of the person suffering from such disease, and such disinfection or cleansing and renovation shall be performed by the owner or occupant of said premises when ordered by the Board of Health. AUTHORIZING RENOVATION OF PREMISES. (p) All filthy and dirty walls and ceilings of any building, including the walls and ceiling of the cellar thereof, shall be thoroughly cleaned and white- washed whenever required by the Board of Health. REQUIRING NOTIFICATION OF GLANDERS. (q) Every veterinary surgeon who is called to examine or professionally attend any animal within the City of New York having glanders or farcy or any contagious disease, shall report forthwith in writing to tlie Board of Health of said city the fol- lowing facts, \iz. : 1st, a statement of the location of such diseased animal; 2d, the name and address of the owner thereof ; 3d, the type and character of the disease. REQUIRING DESTRUCTION OF GLANDERED ANIMALS. (r) No person shall keep, retain or allow, or cause to be kept or retained at any place in the City of New York, any animal having the disease known as 27 glanders or farcy, or any other contagious disease, but shall forthwith report every such case and the lo- cation thereof to the Department of Health; the Sanitary Superintendent or an Assistant Sanitary Superintendent of the said Department shall cause every such animal to be destroyed and the body thereof removed and disposed of in such manner as shall be by him designated. REQUIRING TAGGING OF DEAD HORSES. (s) All dead horses, before they are placed in the street, must have a tag attached giving the name and address of the owner and the stable from which the horse was removed. AUTHORIZING DESTRUCTION OF RABID ANI- MALS AND VICIOUS DOGS. (t) Every animal which shows symptoms of rabies and every animal that has been exposed to such dis- ease shall, by the person owning the same or having possession thereof, be at once confined in some secure place for such length of time as to determine whether such disease exists or to show that such exposure has not given such animal said disease, and so as to avoid all danger to life or health. And such person shall also forthwith notify the Department of Health thereof and of the place where such animal is con- fined. Every animal which is mad or has rabies shall at once be killed by the owner or person having pos- session thereof, or by the Department of Health, and the body of any animal that has died of such disease, or being suspected of such disease has been killed, shall be at once surrendered to the Department of Health to be by it disponed of. 28 Should a dog bite any person it shall be the duty of the owner, or person having the same in his pos- session or under his control, to at once notify said Department thereof, and surrender said dog to said Department for inspection and observation; and such dog shall be returned to the person from whom the same shall have been received if found not rabid or vicious, and if found to be rabid or vicious to such an extent as to be unsafe to be at large, it shall be de- stroyed by said Department. When the police or other person or authorities de- stroy a dog for any of the causes herein mentioned, it shall be his or their duty to immediately notify the said Department thereof and of the location of its body, so that the same may be obtained by the said Department ; and it shall be unlawful to remove any such dog or the body of any such animal here- tofore mentioned except as herein provided. FORBIDDING SPITTING ON SIDEWALKS, ETC. (u) Spitting upon the sidewalk of any public street, avenue, park, public square or place in the City of New York, or upon the floor of any hall in any tene- ment house which is used in common by the tenants thereof, or upon the floor of any hall or office in any hotel or lodging house which is used in common by the guests thereof, or upon the floor of any theatre, store, factory, or of any building which is used in common by the public, or upon the floor of any ferry- boat, railroad car or other public conveyance, or upon the floor of any ferryhouse, depot or station, or upon the station platform or stairs of any elevated rail- road or other common carrier, or into the street from 29 the cars, stairs or platforms of the elevated railroads, is hereby forbidden. The corporations or persons ovv'niug or having the management or control of any such building, store, factory, ferryboat, railroad car or other public con- veyance, ferryhouse, depot or station, station platform or stairs of any elevated railroad or other common carrier, are hereby required to keep permanently posted in each of said places a sufficient number of notices forbidding spitting upon the floors and calling attention to the provisions of this section. It is hereby made the duty of every corporation or person engaged in the manufacture of cigars, cigar- ettes or tobacco, or conducting the business of print- ing in the City of New York, where ten or more per- sons are employed on the premises, to provide proper receptacles for expectoration. Such receptacles are to be in proportion of one for every two persons so employed, and they are to be cleansed and disinfected at least once in every twenty-four hours. A copy of the preceding paragraph must be kept posted in a conspicuous place in every factory or printing office mentioned therein. REGULATIONS APPLYING TO ALL EMPLOYEES. TEMPORARY APPOINTMENTS. Sec, 5. Temporary employees appointed because of non-existence of Civil Service eligible lists are ex- amined by the Civil Service Commission within fifteen days after appointment and if successful in passing, continue to serve until a new eligible list is announced. 80 EXAMINATION OF NEW EMPLOYEES. Sec. 6. All new employees are vacciDated and un- 5i dergo a physical examination when entering the serv- i] ice. They are re-examined and re-vaccinated from -| time to time, a record being kept of these exami na- il tions (Form 23 E). Immunization against typhoid 1; fever is recommended. PROBATION PERIOD. Sec. 7. Each employee appointed from the Civil Service eligible list is placed on probation for a period of ninety days. Reports as to quality, etc., of work are forwarded by the superior officer at the ex- piration of thirty, sixty and seventy-five days re- spectively. If unsatisfactory, employee must be so no- tified. FORBIDDING FEES. Sec. 8. No physician, nurse, or other employee of the Department of Health is to accept money or other gratuity for acting in any ofiicial capacity. ABSENCES FROM DUTY. Sec. 9. Whenever an employee is absent, said em- ployee is to telephone or telegraph the fact imme- diately to the office of the superior officer. Within three (3) hours a written notification of absence (Form 21 C) is to be forwarded, stating cause, — if illness, its nature is to be stated. Every employee is expected to keep on hand one or more of these blanks. On return to duty, the employee is to report in person at the office of the superior officer, where a written ap- plication for leave is to bo made out (Form 23 C) stat- 31 Ing dates of absence, inclusive, and, if cause was ill- ness, attaching a pliysician's certificate. Whenever an employee reports that he is unable to perform his duties on account of "illness," "sickness," or other indefinite reason, an immediate investigation is made by a district diagnostician to determine the exact nature of such illness. Each absent employee is examined at least once each week by a district diagnostician, who reports in writ- ing the physical condition and the reason for continued absence, together with a recommendation that such employee immediately report for duty, if, in the opin- ion of the district diagnostician further absence is unnecessary. Under no circumstances may employees, absent from duty for any cause, leave the city without a written statement of that intention being made to their superior officer, and the employees subsequently being notified that such permission has been given. Per- mission to leave the city will only be given when the employees inform their superior officer where they may be readily reached by mail. ABSENCE WITH PAY. Sec. 10. Tbis is granted under the following con- ditions : A. — Civil Service Examinations: Absence with pay is granted for attendance at examinations for promo- tion within the Department, but not for attendance at examinations for appointment outside the Department. B. — Conventions: No absence with pay Is allowed for attendance at conventions, except where it is as a 32 representative of the Department, or permitted by leg- islative act. C. — Court Attendance: (1) Absence without pay is granted where presence at court is required of a phy- sician of the Department, in his professional capacity, for pay; (2) absence with pay is granted where presence at court is required on non-departmental business, when there is no other compensation than that prescribed by law : (3) absence with pay is grant- ed for attendance at court on Department business. D. — Deaths in Family: In case of death in imme- diate family (husband, wife, children, parents, broth- ers or sisters), three days' absence with pay is granted. E. — Illness: Absence is granted with pay to an ag- gregate of two weeks in any one year to employees who have been more than one year in the service, and to an aggregate of one day for each month of service to emplo3''ees in the service less than one year. But every request must be accompanied by a private phy- sician's or diagnostician's certificate. Absence is granted with pay for illness of more than two weeks, but in no case for a period exceeding six months, only after certification by a family physi- cian and a district diagnostician that the employee was incapacitated from fulfilment of duties for the entire period of absence. The Director of the Bureau recommends such grant of pay, and the recommenda- tion if endorsed by the Conmiittee on Absences is sub- mitted to the Board of Health for its approval. The rule with regard to absence of over two weeks' duration is not to apply to employees of less than one year's standing. 33 F. — Military or 11 aval Duty, G. — Quarantine tor Infectious Diseases. H. — For Religious Holidays: Only such as are per- mitted by the Mayor to be allowed to all employees of City Departments. In the event of any employee being entitled to pay for only a part of the time of his absence, it is neces- sary to forward two applications, one for the time during which he is entitled to full pay, and the other for the time without pay. When an application (Form 23 C) for a leave of absence is filed, where the applicant has already been absent seven days from June 1, a statement must be made on the application, showing: First. Date or dates of absence from June 1 and reasons for prior absence. Second. Whether the prior absence was granted with or without pay. If pay is desired, the employee must also forward a separate formal statement giving reasons for this request. The superior officer of this employee on re- ceipt of this application and statement, will endorse it ns follows: Name of employee, Civil Service title, date of ap- pointment, statement regarding quality and quantity of work performed by him, and reasons for approval or disapproval. Applications for leave not accompanied by statement described above, are forwarded with the recommenda- tion that leave be granted without pay. 84 I NOTIFICATIONS OF ABSENCE. Sec. 11. All notifications of absence and applica- tions for leave of absence, after having been properly endorsed by the official immediately superior to the absent employee, are signed by the Chief of Division or Borough Chief and forwarded to the Director. VACATIONS. Sec. 12. (a) An annual vacation of three weeks is granted to each employee, this to take efCect for the year beginning June 1, 1914, therefore to be oper- ative in the summer of 1915; (b) one week's vacation in addition to the three weeks allowed under preced- ing rule is granted to every employee who has been in the Department twenty years or more. HOURS OF DUTY. Sec. 13. Every medical inspector is to give to the work of the Bureau at least three and a half hours daily, except on Sundays and legal holidays, but an inspector may be required to exceed these hours if the necessities of the service require it. Nurses de- vote at least six hours daily to their work. Saturday being a half holiday by statute, three hours constitute a Saturday's work. Any employee of the Department of Health found to have tampered with the time clocks located in the various offices of the Department, or to have altered or falsified the time cards attached thereto, will be subject to dismissal from the Department of Health without further warning. All officers of the Bureau are charged with the aaily inspection before 10 A. M., of the time clock 35 cards of every employee of the Bureau under their supervision, using such cards. Tardiness of em- ployees is thus taken up at once. Tardiness or absences for unsanctioned causes may result in reduction of pay. A monthly summary of time, tabulated from the daily reports of each employee of the Bureau of In- fectious Diseases not using time clock cards or time sheets, is forwarded to the Executive Office and there kept on file. The hours of duty of all clerks, laboratory assist- ants, laborers, etc., are from 9 A. M. until 5 P. M., but an employee may be required to exceed those hours, if, in the opinion of his superiors, the neces- sities of the service require it. The luncheon time of the clerks, stenographers, typists and all other employees on duty in the offices, is not to be longer than one hour, and is to be taken only between the hours of 12 M. and 2 P. M. DAILY REPORTS AND TIME RECORDS. Sec. 14. Every employee of the Department of Health keeps a daily record of his hours on duty, and nature of work performed. Clerks, stenographers, and laboratory assistants register hour of arrival and departure daily on the time clocks at each Borough Office. Diagnosticians, inspectors and district nurses submit a daily report of work performed, the name and address of each case visited, the hour of arrival at the same, the nature of the assignment and the number of hours on duty. All other employees, with- out exception, submit the regulation time sheet (Form 23 A), showing hours on duty, etc. Each time sheet 36 covers a period of ten days, and is to be submitted immediately on its completion. Every time card and time sheet must state the title, location of office and nature of the duties performed. Employees who visit more than one office or locality in the performance of their duties, must state on the bacli of said time sheet the places other than head- quarters visited, and the time spent thereat. Time unaccounted for is supposed to have been spent at headquarters. COMPLETION OF DAILY BUSINESS. Sec. 15. All current business in each office of the Bureau is completed daily without regard to hours, before the office is closed, or the clerks leave for the day. INFORMATION FOR PUBLIC. Sec. 16. No information of any kind is given to the "public except when authorized by the Director of the Bureau. The names of complainants are never iivulged by anyone connected with the Department Df Health. Communications to co-ordinate branches Df the city government are forwarded through the Executive Office. TELEPHONE REGULATIONS. Sec. 17. Departmental telephones are not to be ised for personal business. Permission to use the De- lartment telephones may, however, be granted by the )irector or his duly authorized representative, in case )f emergency. The date, name and telephone num- )er of person called, the name of person using the olephone, and the amount of the telephone charge, 37 together with the money collected, are to be for-, warded monthly to the Auditor of the Department of Health. A telephone journal (Form 4 LL) for all out-of-Borough and personal caHs and showing the above items, is kept in every Branch Office, Clinic and Day Camp, and also at the Hospital Admission Bii reau. CARE OF DEPARTMENT PROPERTY. Sec. 18. The property of the Department of Health entrusted to the care of employees is to be kept in perfect order. Breakage or impairment is reported immediately, in writing, to the Director of the Bu- reau, with an explanation of the cause. All desks are to be kept in an orderly and cleanly condition. All ink-wells to be cleaned and refilled in all offices as often as may be necessary, and at least once a week. All pen-holders and pens are to be kept in a cleanly condition. All typewriting machines are to be kept thoroughly clean, and in such condition that the typewritten mat- ter will present a neat appearance and be plain and distinct. Large blue blotters are to be provided where needed and charged as soon as they become soiled or other- wise unfit for use. No small calendars, advertisements, superfluous cards, or other unnecessary ornaments are to be hung up or posted on walls or partitions in the various offices. 38 Letter-paper belongiug to the Department of Health is to be used for Department of Health purposes only. Desks and tables are to be cleared as far as possi- ble at the close of business each day, and all roll- top desks closed. All blanks and stationery are to be neatly stowed away in closets or cabinets for such purposes, and kept in a proper and careful manner. No Avaste paper or other waste material is to be thrown on floor ; waste baskets are provided. Each individual is held directly responsible for the condition of the desks and tables used by him, and is always to keep the same in a neat and cleanly jondition. j All records, reports, correspondence and copies of orrespon deuce connected with the work of the Bu- •eau of Infectious Diseases are to be properly filed )efore the close of the day's work. In no instance ire any such reports, records, correspondence, or opics of correspondence to be put into the drawers )r pigeon-holes of desks. VIOLATION OF SANITARY CODE. Sec. 19. Any violation of the Sanitary Code com- ng under the observation of an employee of the Bu- eau is to be reported in writing. SMOKING. Sec. 20. Smoking and the drinking of intoxicating iquors during ofiice hours are strictly forbidden. 3U KNOWLEDGE OF REGULATIONS. Sec. 21. Every employee of the Bureau is ex- pected to familiarize himself with all sections of this Handbook which apply to himself or his duties. REGULATIONS APPLYING TO ALL OFFICERS. MONTHLY CONFERENCES. Sec. 22. A conference of the Chiefs of Division and Borough Chiefs is held at 2 P. M. on the second Tuesday of each month, notice of same being for- warded (Form 279 L). Recent orders and new pro- ceedings are discussed. A similar conference of the Borough Chiefs and physicians-in-charge of Branch Offices is held at 2 P. M. on the third Tuesday of each month. Similar conferences of diagnosticians, veteri- narians, clinic physicians, nurses, etc., with their re- spective Chiefs, are held at regular intervals. CORRESPONDENCE AND REPORTS. Sec. 23. Complaints (personal, telephonic, and written), and requests for information, received at the Executive Office, are entered in a journal (Execu- tive Office, Form 6 LL; Borough and other Offices, Form 19 LL) and referred to the proper officer of the Bureau. If referred "for investigation and report," a memorandum of the original records is to be returned to the Executive Office. If "for investigation" only the matter is to be ffiially disposed of, and acknowl edgment made directly to the complainant by the offi cer, the papers being returned for final reference to th( Central Filing Bureau. Similar communications made directly to an office] of the Bureau are to be investigated, and disposed o: 40 by him, or if bis judgment so dictates referred to the Director. All matters dealing with the policy of the Department of Health are to be referred to the Ex- ecutive Office. Carbon copies of all correspondence, reports, etc., are tiled according to subjects and cross referenced by means of a card index of names and addresses. Every report, complaint, etc., of which there is no carbon copy, is journalized before being forwarded. All papers received at, or forwarded from the Executive Office, are journalized there (Form 6 LL). CENTRAL FILING BUREAU. Sec. 24. The central filing bureau for all com- pleted correspondence, discarded records, etc., is lo- cated in the office of the Secretary of the Department of Health, at Centre and Walker Streets. All com- pleted correspondence is to be forwarded to the Exec- utive office, securely wrapped in packages of conve- nient size, marked "For Central Filing Bureau." Each package should be clearly labeled with a description of its contents, and the name of the office from which it comes. All cards, records, etc., that are no longer in use should be forwarded in the same way. Climes and Borough Offices should forward histories of dead cases of tuberculosis dating back two years, and old typhoid and other histories ; the Diagnosis Laboratory and Borough Offices, all specimen slips no longer in active use ; the Branch Offices, all old daily reports to and from the Borough Offices, and all "discontinued cases" more than two years old. These records can be consulted at any time, or obtained on request. 41 GENERAL DUTIES. Sec. 25. Officers must properly indorse and for- ward to tlie Executive Office all bills, requisitions, reports, applications for leave of abs'ence, carfare and telephone bills, and immediately upon receipt of all goods must sign and forward receipt for same (Form 228 L). Tbey must forward a vacation schedule for employees under their supervision, to the Executive Office by May 1st of each year. They must keep a diary of the daily events, de- linquencies, etc., occurring in their offices or among those under them, and in making reports to the Director, specific facts, dates, etc., must be given. The diaries are inspected at the close of each yenr. All delinquencies of subordinates are also recorded in a card index. All complaints received are to be forwarded to the comijlaint clerk of the Borough, who will enter them in his journal and return them for investiga- tion. All reports are made on the Bureau letter-head (Form 131 L). SPECIAL DUTIES. Sec. 26. (a) Director. The Director has full au- thority over all branches of the work of the Bureau. He informs the Commissioner from time to time as to the character and amount of work performed by the Bureau and forwards such written reports as may be required. He supervises the work of the Bureau, directs the detailing of all employees, and makes such changes in the methods employed as will best carry out the work of the Bureau. 42 In the absence of the Director, the Medical In- spector, detailed as Assistant to the Director, is in charge of the work of the Bureau. A special assignment slip is used in this office (Form 19 L). (b) Chiefs of Division. The Chiefs of Division exercise general supervision over all matters pertain- ing to the work of their particular divisions through- out the city. (c) BoEOUGH Chief: Each Borough Chief is re- spousible for the notification, registration, sanitary su- pervision, disinfection and removal to hospital (when necessary) of all cases of infectious diseases, includ- ing tuberculosis, occurring in his borough. He is also responsible for the registration of glanders and dog bites. He submits and records the following reports : Daily telephone report to the Executive Office be- fore 9.15 A. M. each day, of the work of the Bureau, absences, etc., in the Borough for the preceding twen- ty-four hours ; the number of new cases of tuber- culosis. Weekly summary of new cases of tuberculosis for preceding week, by telephone, to Executive Office every Monday morning. Weekly report to the Executive Offi-ce (Form 230 L) to be used in compiling the weekly report of the Bureau to the Conuuissioner. In a loose leaf record (25.0 L) is recorded the weekly summary of the daily reports of each inspector, so that his work for the year can be seen at a glance. Monllily summary to the Executive Office of total number of hours on duty of each inspector. 43 Inventory of stock of blanks on the fifteenth day ol January, May and September, and report of same tc the Executive Office (Form 53 L). Annual and semi-annual reports to the Director of Bureau, of work performed in the Borough. Daily record of number of new cases of tubercu- losis and how reported, number of cases among chil- dren, and other data. There is kept on a bulletin board (a) the list of supply stations in the Borough; (b) a list of Sunday,! holiday and night assignments of inspectors ; and (e) all current orders, notices, etc. All reports of cases of tuberculosis from private physicians, whether by postal or positive laboratory specimens, are acknowledged by letter (Form IG L). (d) Physicians-in-Chakge. Each Physician-in- charge is responsible for the registration and sani- tary supervision of all infectious diseases in his dis- trict unit, the conduct of his clinic and for the work of all employees attached to his office. He is the head of the district organization and is responsible for the accuracy of all reports and files as well aa the prompt disposition of cases assigned. REGULATIONS APPLYING TO FIELD WORKERS. DAILY REPORTS. Sec. 27. All field workers (district diagnosticians, inspectors, district nurses, veterinarians, disinfectors, etc.) submit a daily report of work performed (In- spectors, Form 108 L; Nurses, Form 259 L; Veteri- narians, Form 16.5 J; Disinfectors, Form 169 J), in- 44 eluding hour of arrival at each assignment, and total number of hours on duty. These reports are made out at the office of the district to which these em- ployees are detailed, forwarded to the Borough Office each day in addressed envelopes (Forms 91, 100 and 114 L) and there kept on file. At stated intervals the correctness of these reports is investigated by another inspector or nurse, who repeats each visit paid the day before, and submits a report (Form 4 L). I SEARCH FOR NEW CASES. I Sec. 28. Every Diagnostician, Medical Inspector, 'Clinic Physician or Nurse, when entering for the first time any building used for residential purposes, in- quires of the janitor or person in charge as to the ex- istence of any cases of illness on the premises. If 'informed that any such cases exist, they are at once inquired into. This is understood as included in all ^instructions regarding assignment of district work. The above employees carry postal cards for reporting ases of infectious diseases. BADGES. Sec. 29. Each physician and nurse must wear the Department badge while on duty. It must not be carried in their pockets, bags or card cases. PERSONAL ATTENTION TO ASSIGNMENTS. Sec. 30. Unless otherwise specifically stated, all issignments require that the inspector or nurse visit premises in person. Information obtained by tele- ohone is not to be submitted as a report of an iuspec- :ioD. 45 CARFARE AND TELEPHONE BILLS. Sec. 31. Certain employees of the Bureau whc spend money for carfare and for telepbone servict while engaged in tlie performance of their official duties, are reimbursed by the Department of Health Each 5-cent item spent for carfare is accounted foi by giving points to and from which the car wa^ taken. The first and last fare of the day must no1 be charged, nor is carfare allowed between the em ployee's house and the Borough Office. Intersecting points and not house numbers must be given. Eact 5-cent item spent for telephone service is accountec for by giving the number of the stations to and fron which the call was made. Unintelligible abbrevia tions must not be used. At the end of each montt the employees sign and swear to their monthly bilh at the respective Borough Offices. The carfare and telephone bills (Forms 243 anc 244 L) are made out in duplicate, signed and swori to by the employee, certified by his or her superio], officer, and forwarded to the Director by the fifth da3 of each month. A record is kept of the amount, dat( of receipt and date of forwarding of each employee's bill. All bills are then certified to by the Director anc forwarded to the Auditor of the Department ol Health. When the bills are paid, the checks are sen! to the Chiefs of Divisions, who distribute the money obtain receipts from the employees and returr them to the Executive Office. Collectors are paid their carfare in advance, fron two special funds of $500 each, provided for that pur pose, giving receipts (Form 94 L) for amount re 46 ceived. Their bills must be approved by the Assistant Director of the Diagnosis Laboratory. At the end of each month they submit sworn vouchers, showing how money was used. These vouchers are submitted to the Department of Finance in lots of $500. ROUTINE PROCEDURE— EXECUTIVE OFFICE. DUTIES OF CHIEF CLERK. Sec. 32. The Chief Clerk of the Bureau is respon- sible for the proper performance of the following routine duties : REPORTS. Sec. 3.3. A daily report to the Commissioner giving the number of cases of infectious diseases reported during the preceding twenty-four hours as compared with the corresponding date of the previous year (Form 185 L). Copies are also mailed in envelopes (Form 6 J) to the Health Officer of the Port, Acad- emy of Medicine (Form 3 J), and to the State Board of Health (Form 8 J). A weekly report every Wednesday to the Commis- sioner of the work of the Bureau (Form 13 L), com- piled from the weekly reports of the Chiefs of Di- vision and Borough Chiefs, Superintendent of Nurses, Hospital Admission Bureau, and the Assistant Direc- tor of the Diagnosis Laboratory. The complete re- port for each week is copied in a loose-leaf record (Form 255 L). Similar quarterly, semi-annual and yearly reports are submitted giving the figures compiled from the weekly reports during those respective periods. A monthly pay-roll is forwarded on the ]5th of each month, giving the name, title, and current salary of every employee on active duty in the Bureau. 47 OFFICE OF SUPPLIES. Sec. 34. All matters concerning supplies, blanks repairs and alterations, and bills for the same, an cared for by the Orliee of Supplies. Borough and Division requisitions . (Form 59 L] for all requirements are referred to this office. Department requisitions (Form 08 B) are thei made out, and after approval and signature oi Director, are forwarded to the Commissioner for his approval. If approved, a notice to that effect is re ceived from the Chief Clerk of the Department ol Health. All requisitions, orders and bills are filed in large manila envelopes (Form 118 L). When goods have been delivered and accepted, a receipt (P'orin 228 L) is to be forwarded immediatelj to the Executive Otfice. Consignors are required to submit their bills in quadruplicate, accompanied by the original order. A "received" stamp is placed on the back of three bills, and they are signed by the employee accepting the goods. Certification slips (Form 197 L) are attached to two copies, signed and forwarded to the Auditor of the Department of Health. Employees receipting bills are held responsible for the proper fulfillment of the order. The quadruplicate copy of the invoice, to- gether with a statement (Form 4 C) showing name of vendor, articles received, and l)y whom received, is forwarded to the Auditor and by him to the Division of Inspections, Department of Finance. A requisition is forwarded on the first of each month for the regular current expenses of the 48 Bureau — ice, express charges, drugs, carfares, tele- phone calls, food for camps, repairs to instruments, blood for the preparation of culture media, carfare expenses of employees, etc. RECORDS, BLANKS, ETC. Sec. 35. Each of the blanks, circulars, leaflets, en- velopes, record books, etc., has a form number by which it is known, the letter "L" or "J" placed after each number indicating the Bureau of Infectious Diseases. Two "L's" or two "J's" indicate a bound record. A complete record is kept of each blank on the outside of large manila envelopes (Form 115 L) filed serially, showing the date and amount of all special and annual requisitions, date of proof, receipt, and the date the printed matter was received. The stock on hand at the end of every four months is also shown. The envelopes contain three of the latest samples of each form. A card index, arranged ac- cording to subjects and titles, is also used as a cross reference. The annual requisition for blanks, stationery, etc., is forwarded to the Chief Clerk of the Department of Health on the first of July of the preceding year. The form number, description, estimated amount used monthly, and the number needed for each Borough are stated. A sample of each form ordered must be forwarded with the requisition. Supplies of blanks, etc., are forwarded to Borough Offices in special envelopes (Form 253 L). EFFICIBx>JCY RATINGS. Sec. 36. On November 10th, 1913, with the ap- proval of the Commissioner, the Director appointed a 49 Committee on Grading and Efficiency to consist of five members. The Medical Inspectors, Clinic Phy- sicians, Nurses, Laboratory workers, and the Clerical Staff of the Bureau, are represented on this Com- mittee. This Committee supervises the efficiency ratings of the employees of the Bureau, subject always to Civil Service requirements. Each employee is rated by the superior officer in closest touch with his work. Ratings received by superiors, if approved, are forwarded without change; if not approved, they are forwarded with necessary comments and explanations. A permanent record of quarterly ratings is kept in each Borough and Division Office (Form 28B). At the end of each quarter, each rating official for- wards to the Committee a list containing name, Civil Service title, date of appointment and rating of each euiployee rated by him. If the rating is above or below "average" an explanation must accompany it on card (Form 93 L). All delinquencies are noted on the quarterly rating card. Employees are rated according to following schedule : 1. Quality of work 30 (a) Results obtained 20 (b) Promptness 5 (c) Care of property 5 2. Quantity of work 20 60 General conduct 20 (a) Willingness 5 (b) Courtesy 5 (c) Neatness 5 (d) Personality 5 Executive ability and capacity for initiative. . . 20 (a) Executive ability 10 (b) Capacity for initiative 10 Attendance 10 INFECTIOUS DISEASES. GENERAL PROCEDURE. BOROUGH OFFICES. Sec. 37. A Borough Office of the Bureau is located n each of the five Boroughs of the City. (See Directory Sec. 2.) Each Borough Office is under the 'lirection of a Borough Chief and has a staff consist- ing of a Borough Diagnostician, Chief Clerk, Disin- I'ector-in-charge, clerks and stenographers. At these )ffices are registered and eventually filed all cases of nfectious diseases occurring in the Borough. NOTIFICATION OF INFECTIOUS DISEASES. Sec. 38. The Department of Health is notified by aw of all cases of infectious disease occurring in the Dity of New York. These cases are reported by — a. Private physicians — (1) in writing. (2) by laboratory specimen. [Note. — Delinquent List. The names of those phy- sicians who fail to promptly report the cases of infec- :ious diseases (Sanitary Code Sec. 4 A) under their 51 professional care, are forwarded to the Executive Of fice on a special card (Form — L). Upon the occur rence of a second offence, legal proceedings may be instituted.] b. Institutions. When a case of infectious disease occurs in an in stitutiou the Department of Health is at once notified by telephone. Note. — (Cases of tuberculosis are reported by tele phone to the Hospital Admission Bureau, which in turn reports the cases to the Borough Offices of the Department of Health.) The Tuberculosis Clinics (Department and Non Department) report daily to the local Branch Office and thence in turn to the local Borough Office (Form 94 L). [To facilitate the collection of this informa- tion and obviate delay, confusion and error, special record books are furnished to each Non-Department Clinic (Form 9 LL.)] Tuberculosis sanatoria report their cases by mail on blanks furnished for that purpose (209 L), to the Hospital Admission Bureau, which in turn reports to the Branch Offices of the Department of Health. c. Deaths from infectious diseases are reported by the death certificates forwarded by the attending physician to the Bureau of Records of the Depart ment of Health, and thence to the Borough Office of the Bureau of Infectious Diseases. d. Complaints from lay individuals or organiza- tions, and by employees of the Department of Health and other branches of the City Government. Inspec- tors (Form 4.3 J), Sanitary policemen (Form 39 J). Policemen report on Form 175 J. 52 e. Nurses and visitors of charitable organizations ■eport cases coming under observation on a special 'ard (Form 277 L). Every case of infectious disease •eported is acknowledged. REGISTRATION OF INFECTIOUS DISEASES. Sec. 39. All cases reported are registered at the Department of Health and all necessary steps are aken to render both notification and registration as Lccurate and complete as possible. The system of registration for all infectious dis- eases is essentially uniform. In tuberculosis, because ►f the prolonged period of supervision for each case, he system has been considerably elaborated. This system of registration and sanitary super- 'ision, depending as it does upon the subdivision of ;ach Borough into co-ordinate parts, and locating herein the records of the infectious diseases of that )art has greatly increased the accuracy, flexibility md ethciency of the work. A great amount of dupli- ;ate reporting and copying has been done away with, md a more complete control of the nurses both as to he quality and quantity of work done has been at- ained. RECORDS AT BOROUGH OFFICES. Sec. 40. All cases of infectious diseases reported the Department of Health are registered at the )ffice of the Borough in which they occur. The in- ormation thus received is forwarded to the proper Branch Office, by telephone and daily written report. The results of examination of diphtheria cultures, idmissions to and discharges from hospitals, and 53 deaths, are reported to the Branch Office daily on i special blank (Form 23 J and 89 L). A daily report (Form IJ) of new and discontinue( cases of infectious diseases, with corresponding fig ures for the preceding year, is forwarded to the Ex ecutive Office. A list of all new and discontinued cases of infec tious diseases is sent daily to the printer. The printet lists are mailed by the printer in envelopes furnishe( by the Board of Education to public schools, and t( others, iu envelopes furnished by the Department o: Health (Form 80 J). The following records of cases of infectious diSi eases are maintained: (a) General Envelope Name File of current cases of diphtheria, measles, scarlet fever, typhoid fever cerebro-spinal meningitis, acute poliomyelitis anc smallpox. When an envelope is temporarily removed a tally card (Form 13G J) is substituted therefor. (b) House File. — Every case of the more import ant infectious diseases, with the exception of tuber culosis, is entered by name on a house card (Form 9.5 L), which is filed in the Borough Office. [The tuberculosis house cards are filed in the Branch Offices.] All subsequent cases reported from that ad- dress are recorded on the same card. If not found at the address given, that fact is noted later in column "Location of Apartment." [In private physicians' cases of tuberculosis, the physician's report is ac- cepted and the case entered on the house card, the address being verified by the district nurse. In cases reported by non-Department clinics, the nurses of that clinic district obtain the desired information regarding 54 the house and forward it on a special card (Form 149 L).] On the house card are entered: (1) The street and number, the Borough, the number of stories in the house, the material of whicli it is built, if built before or after 1901 (the year the new tenement law went into effect) ; its condition, and its character (ten- ement, private house, hotel, etc.), and the number of cases of tuberculosis reported from the house prior to 1910 (the year the house file was begun). All this constitutes a permanent record of the house itself; (2) the name of every patient reported from that house since January 1, 1910, the date case was reported, record number, location and number of rooms, how long patient had been in house, date patient's family left house, what disinfection was performed, and of what rooms, where family moved to, and date of death or recovery of patient. [All living cases of tu- berculosis In the register on January 1, 1910, were 9ntered in this file.] These cards are filed accord- ing to address and take the place of the house maps tvhich (in Manhattan) had been maintained for the irevious fifteen years. Not only are the records of ;reat value in furnishing evidence that a given house (or rooms in that house) is dangerous to live in, but hey also serve to identify patients. Many foreigners ire reported under different names from different '.ources, and can only be identified by such an index is this. When it is ascertained that a house has been orn down, this fact is entered on card and a new card tarted when a new case is reported from the new lOuse. (c) Laboratory file of active cases of diphtheria. (d) Laboratory file of active cases of typhoid fever. 55 (e) Card name file (126 L) of active cases of pul monary tuberculosis. (f) Separate discontinued envelope name files oi terminated cases of, — (1) diphtheria (2) scarlet fever (3) measles (4) typhoid fever (5) cerebro-spinal meniugitis (6) acute poliomyelitis (7) smallpox (S) glanders (0) dog bite (g) Separate report postal address files of, — (1) German measles (2) mumps (3) chicken pox (4) whooping cough (h) Borough envelope name "not found" file of cases of pulmonary tuberculosis. (The general "homeless' file of cases of pulmonary tuberculosis for the greatei City is Isept in the Executive OfQce.) (i) Envelope name file of dead eases of pulmonarj tuberculosis. BRANCH OFFICES. Sec, 41. Each Borough is divided into one or more district units, within each of which is located a Branch Office of the Bureau. (For diagram and boundaries of the districts see Directory, Sec. 2.) Each Branch Of fice is under the supervision of a Physician-in-charge and has a staff consisting of a District Diagnostician, Supervising Nurse, and corps of district nurses, clinic 56 ; physicians, cleaners, etc. All matters pertaining to in- fectious diseases occurring in the district are referred to the Physician-in-charge. At these offices are filed the records of all active cases of infectious diseases, except typhoid fever, occurring in the unit. Upon termination of each case, its records are forwarded to the Borough Office. I BRANCH OFFICE SYSTEM OF REGISTRATION. Sec. 42. The new Branch Office system of registra- tion was introduced late in 1911, and has proven en- tirely satisfactory. It is a return to the old system in vogue prior to 1910. In brief it consists in locating the Irecorda in the clinic districts, so that they may be 'readily accessible to and corrected by the district nurses. The records are given out to the diagnos- ticians and nurses, who make their reports on them. This does away with a great amount of duplicate reporting and copying. Lastly the work of the diag- jnosticians and nurses is under complete control. Their Iday'g work can be laid out the day before, and is ready for them eacb morning. An exact day's work, appor- tioned to the size of the district, can be assigned. Every assignment is reported on the next working morning. RECORDS AT BRANCH OFFICES. Sec. 43. At each Branch Office are located the records of all active cases of infectious diseases occur- ring in the district unit. The district nurses make their reports on the official records of the cases. All new cases of infectious diseases are entered in a djjjly telephone Journal (Form SLL), as they are received from the Borough Office. 57 The following records of cases of infectious diseases are maintained at each Branch Office : (a) General name-file for each nurse's district, of histories of active cases of diphtheria, scarlet fever, measles, typhoid fever, cerebro -spinal meningitis and acute poliomyelitis ; (b) General date tally file according to nurses' dis- tricts, of above diseases. (c) Envelope name-file, according to nurses' districts, of active cases of pulmonary tuberculosis. (d) House file, according to nurses' districts, of cases of pulmonary tuberculosis (see Sec. 40 b.) (e) Date tally file (Form 12G L) according to nurses' districts, of active cases of pulmonary tuber eulosis. (f ) Envelope name file, according to clinic districts, of temporarily discontinued cases of pulmonary tuber- culosis. GENERAL PROCEDURE AT BRANCH OFFICES. Sec. 44. On receipt of report of a case from what- ever source, it is entered in the Borough Office Jour- nal (Form 3LL), searched for in the files and if found to have been previously reported, any new facts received are entered on the records. If a new case, it is at once assigned to the nurse in whose subdistrict it is located. On the arrival at the home the nurse obtains a complete history of the case and takes such further action as the exigency and character of the case demand. The routine procedure followed by an inspector or nurse of the Department in attendance upon any case of infectious disease is described in detail under each disease. All persons (or families oi 58 uch persons) suffering from these diseases are in- tructed as to the proper measure to be taken to pre- 'ent tlieir spread. According to the results of the investigation, cases tre classed as "supervision" cases (visited every few lays) if they need close watching, or as "observation" ases (visited at relatively long Intervals) if kept mder observation only. Every case occurring among school children or teachers is reported to the Bureau >f Child Hygiene through the Borough Office (Form 151J). TALLY OR "TICKLER" FILES. Sec. 4.5. In each Branch Office tally files are kept, )y means of which are assigned to the nurses the primary and later history cards of all cases of infec- tious disease under observation or supervision, which ire to be revisited. On the tally card (Form 126 L) ire entered the name and address of the patient, and iate report is due. Tally cards of all new cases received and assigned are compared with the daily printed list on the fol- lowing morning to make certain that every case has been received and assigned. TALLY SHEETS AND WEEKLY REPORT. Sec. 46. Large daily tally sheets (Form 36 L for tuberculosis. Form 42 J for other infectious diseases) are kept posted in each Branch Office. On these are ' entered the number of additions to and removals from tlu' active files, the results being totaled daily. On these slicets are also recorded the number of new cases, duplicates and deaths reported; the removals calling for disinfection, and the disinfections and renovations 59 ordered, and other items for the weekly report of the Branch Office (Form 35 L). DAILY REPORT TO BOROUGH OFFICE. Sec. 47. Each Branch Office forwards a daily re- port to the Borough Office by collector (Form 94 L). It is begun in the clinic the day before, and gives all information obtained from the tuberculosis clinics and district nurses as to new cases, change of address or of class, deaths out of city, duplicates, — in short, all information required by the Borough Office to correct the central name files. These reports are returned from the Borough Office the following day, and are filed in a loose-leaf binder together with the corres- ponding daily report from the Borough Office (89 L). The two thus constitute a daily journal. (The daily reports from the Borough Office are submitted to the clinic for correction of its records before being filed.) DIVISION OF CONTAGIOUS DISEASES. Sec. 48. The Division of Contagious Diseases is re sponsible for the notification, registration, sanitary supervision, diagnosis, isolation, removal to hospital, and disinfection in all cases of infectious diseases (except tuberculosis, typhoid fever and venereal dis- eases) occurring in New York City. The registration, sanitary supervision and care of small-pox, cholera, plague, yellow fever, typhus fever, diphtheria, measles, scarlet fever, chicken-pox, German measles, mumps, whooping cough, cerebro-spinal men- ingitis, acute poliomyelitis, tetanus, anthrax, glanders (human), leprosy, trichinosis, malarial fever and ery- sipelas by the Division of Contagious Diseases are organized as follows: 60 CHIEF OF DIVISION. Sec. 49. The Cbief of Division exercises general supervision over all matters pertaining to the work of the Division throughout the City. The Chief Diagnostician, and the Physician-in-charge Df Ambulances, Disinfecting Stations and Stables re- port to him. DUTIES OF CHIEF DIAGNOSTICIAN. Sec. 50. The Chief Diagnostician sees all cases of actual and suspected small-pox, typhus fever, yellow fever, cholera, plague and human glanders, also all doubtful cases of adult chicken-pox and all doubtful and disputed cases of other infectious diseases. He holds monthly conferences with Borough and District Diagnosticians and holds clinics in Department hos- pitals on all suitable cases of special interest. He keeps a record of the correctness of the diagnoses of District Diagnosticians and of Institution Inspectors in connection with cases removed to Department hos- pitals, reporting all errors discovered to the diagnos- tician at fault. DUTIES OF BOROUGH DIAGNOSTICIAN. Sec. 51. Borough Diagnosticians relieve the Bor- ough Chief and inspect adult cases of chickenpox and 8uch other cases as, in the absence of the proper district diagnostician, may be referred to them by the Borough Offices or by the Chief Diagnostician. CI DUTIES OF DISTRICT DIAGNOSTICIAN Sec. 52. A. (1) The District Diagnostician is on duty at al hours. (2) Each morning (except Sundays and holi- days) he reports in person at the Branch Office of his district before 10 :00 A. M., in order to receive assignments for the day. (3) Special cases are given to him after assign ing hour by the Branch Office, and after office hours by the Borough Office through the telephone. (4) Before leaving district he calls Branch Office by telephone to receive cases and report on special cases (for removal, for instance). (5) He again calls up the Branch Office before the closing hour of the latter. (6) Relief — In order to be relieved from duty temporarily a district diagnostician may make arrangements with another Diagnos- tician to take his work, but before absent- ing himself must notify the Branch Office, which will in turn notify the Bor- ough Office. B. — He performs immunization for diphtheria on request of nurses or others (if possible at hour sug- gested). If unable to obtain consent to immunize, he will make every effort to have the same performed by the private physician. 62 O. — He examines and makes out removal slips for ases requiring removal to hospitals. Also informs amily of destination of ease, together with address nd telephone number of the hospital. D. — He diagnoses cases on the request of private hysicians and Department nurses, and such other ases as are in dispute. E. — He investigates cases of cerebro-spinal menin- itis and poliomyelitis, secondary visits being made by urses. F. — He investigates absences of Department em- ■loyees. G. — He issues special school certificates. DISTRICT NURSES. INSTRUCTIONS. ON FIRST VISIT. !ee. 53. 1. Locate janitor and inquire if anyone in the build- ng is sick with any infectious disease and without a >hysician in attendance. 2. On arrival at apartment of patient . (a) Inspect quarantine; (b) Get necessary data for history card (20 J) ; (c) Exclude teachers and scholars, make out exclusion postal card (Form 14 J) and inform family that teachers and pupils must not attend any schools ; (d) Note on history card (20 J) whether case Is for observation or supervision ; G3 (e) Ascertain what members of the family have had this disease. Enter same on history card ; (f) State number to be immunized and by whom ; (g) Deliver hanging card calling attention t' details relating to this case ; j (h) Where rooms are back of store or entranr ( to same is through the store, inform fain ■ ily that store must be closed or case re-| moved to hospital ; (i) Ascertain the occupations of members c»i family; teachers and persons engaged ini handling of foods must change address or I stop work ; it is necessary for teachers to have special school certificates in order to re-enter school ; (j) If manufacturing is being done in a home, where there is infectious disease, direct] family to stop same, notify Branch Ofiice, and order disinfection of goods; (k) If illness is in family of superintendent or janitor, inform him he must stop work or reside elsewhere ; (I) Post placard in tenement houses, lodging houses, boarding houses, furnished room houses and two-family houses with com- mon entrance; (m) Take cultures from patient and other members of the household, only when re- quested. 64 ON REVISITS. ec. 54. 1. Determine if quarantine is observed. If not ob- 2rvecl, warn family and notify Brancti Office. In case f second violation, telephone Branch Office. 2. Ascertain if secondary cases have appeared in the imily; if so report to Branch Office as a suspected ase. FINAL VISITS. ec. 55. A. — DipJitheria. 1. Quarantine 7 days. 2. If two successive negative cultures have been taken by the attending physician (or by employee of the Department of Health) remove placard and instruct family re- garding renovation. 3. Issue school certificates as follows : To patient if a school child ; To teachers and pupils who have been im- munized and whose cultures are negative, otherwise wait five days. B. Scarlet Fever. 1. Quarantine 3,5 days, or until patient is free from desquamation (Examine palms and soles carefully) and there is no purulent discharge from the nose or the ear. 2. Order fumigation. (Investigate for library and school books.) 3. Reinspect fumigation. 4. Issue school certificates as follows : To patient if a school child ; To teachers and pupils who have had scarlet fever; otherwise wait five days. 65 C. Measles. 1. Quarantine 5 days after appearance of rasl if otherwise well. (Look for absence o catarrhal conditions.) 2. Instruct as to renovation. 3. Remove placard. 4. Issue school certificates as follows : To patient if a school child ; To teachers and pupils who have ha measles ; otherwise wait fourteen days. GENERAL INSTRUCTIONS FOR NURSES. Sec. 56. 1. Never examine a patient except to terminate scar- let fever. 2. Never comment on treatment or condition of pa- tient. 3. Never take cultures unless requested by family physician or Branch Office. 4. Make every effort possible to have all exposed to diphtheria promptly immunized. 5. If quarantine is violated or not satisfactory, re- port same to Branch Office and note same on history card 20 J. NOTIFICATION AND REGISTRATION. Sec. 57. The procedure for notification and registra- tion has already been described (Sees. 38, 39). Every case reported is acknowledged by postal (Form 35 J). Any departure from the general procedure will be taken up under the individual diseases. 66 SANITARY SUPERVISION. INSPECTION OF CASES. Sec. 58. Nurses make all visits to cases of eonta- ious diseases except those for diagnosis and the jQrst isit to cases of cerebro-spinal meningitis, and acute (oliomyelitis ; these visits are made by the district iagnostician. Upon arrival at the case the inspector or nurse :11s out a history card (20 J), inspects arrangements or isolation, excludes susceptible children or teach- rs, gives verbal instructions and leaves a hanging ard of general information about the disease. Form 270, 271 or 272 L). This card, printed in four inguages, particularly emphasizes the manner in |/hich the disease is spread and the steps necessary for ts efficient isolation. CLASSIFICATION OF CASES. Sec. 59. Cases are visited sufficiently often to main- ain proper quarantine, and are classified, according the ability of the family to appreciate and main- ain satisfactory isolation, into : — A., Supervision Gases, which require visits every ay or every few days, and, B., 01)servation Cases, which require only occasional isits. The occupation of other members of the family is Qvestigated with reference to the character of their 7ork. The dangers of spreading disease may be reatly increased because of the nature of the work [one in the home, or because of the character of he employment of members of the family outside he home. Members of the family are forbidden to 67 continue such home occupations as tailoring, dress making, feathermaking, etc., or to engage in any waj in the handling of foodstuffs. PLACARDING. Sec. 60. Cases of Diphtheria, Scarlet Fever anc Measles occurring in tenement houses, furnished rooms and boarding houses, and two-family houses with com mon entrance, are placarded (Diphtheria, Form 47 J Scarlet Fever, Form 44 J; or Measles, Form 120 J) Private houses and two-family houses with separate entrances are not placarded. The placard in tenemeul houses is placed on the door of entrance from the pub lie hall ; in furnished room houses, boarding houses etc., on the door of the sick-room, and in the two family houses with common entrance, upon the dooi leading from the common hall to the infected apart ment. On Sundays and Holidays, all new cases of diph theria and scarlet fever are placarded by districi nurses. QUARANTINE. Sec. 61. The rules of quarantine are discussed un der the individual diseases. Violations of these rulef will lead to forcible removal. A placard of instructions (Form 282 L) is issued foi hotels and boarding and lodging houses. CHARITABLE ASSISTANCE AND EDUCATION OF PUBLIC. Sec. 62. Charitable assistance or hospital care is provided, so far as is possible, for all cases wishing or requiring such assistance or care. 68 The general public is educated as to the nature of he infectious diseases, the precautious to be taken gainst their spread, the advisability of institution nd sanatorium treatment, etc. The Bureau issues a small booklet of information or physicians, giving the procedure in infectious dis- ases, with a list of supply stations (Form 206 L), nd a circular of information for school children re- arding infectious diseases (Form 216 L). ENFORCED REMOVAL TO HOSPITAL. : Sec. 63. Should a case of infectious disease be found [i a home in the rear of, or communicating with a i:ore, the family is given the choice of closing the :ore, or of permitting the removal of the case to the ;Ospital. I When violations of quarantine are observed by an ispector or nurse, the Branch Office notifies the orough Office of this violation by telephone, confirm- ig the same by written report. The case is then Lsited by a patrolman of the Health Squad, who arns the family that if proper quarantine is not aintained, the patient will be removed. The Branch ffice telephones this information to the attending lysician and solicits his aid in maintaining isola- )n. The case is made a Supervision Case and upon port of a second violation, removal is recommended. s])Ocial report (Form 17 J) stating the character of (' violation is submitted to the Physician-in-charge, lio forwards it through the Borough Office to the I iff of Division, When approved by the latter, the trough Chief is authorized to remove the case. He 'tifies a stable of the Department of Health, and an G9 ambulanee is sent for the patient. When necessarj_ the ambulance surgeon is aided by a policeman. All removal cases are visited by a district diai nostician who confirms diagnosis before sending patiei to hospital and leaves a removal card (Form 10 J for the ambulance surgeon, at the patient's home. TERMINATION OF CASES. Sec. 64. Cases are terminated by recovery, deat] removal to hospital, or change of diagnosis (on rt ceipt of written statement from the physician thi original diagnosis was in error). Inspection is madi to order fumigation, to give instructions as to rem vation; to issue school permits and to remove pla ards. DEATHS FROM INFECTIOUS DISEASES. Sec. 65. All deaths from infectious diseases, inclu< ing typhoid fever, tuberculosis, whooping cough, et( are reported by death certificates submitted to tl Bureau of Records of the Department of Health. Ui dertakers must also certify (Form 41 J) that all pr cautions have been talien. A. — Procedure in Bureau of Records. If death certificate is received during office houi of the Department, it should be at once referred to tl Bureau of Infectious Diseases for comparison wil records, and "O. K." and signature by the officer i charge of the Borough Office of that Bureau. Tl burial permit will then be issued. If certificate is received before or after Depar mental office hours, it is forwarded to the Bureau < Infectious Diseases, the morning of the next workii 70 Jay. In cases of diphtheria (croup), scarlet fever, measles, cerebro-spinal meningitis and acute poliomye- litis, the medical clerk should ascertain from under- taker if case was reported to Department of Health luring life. (In case of diphtheria, scarlet fever, and measles, placards should have been posted.) (a) yVhere case has been previously reported, and where ;he Department of Health will be open the following lay, the burial permit should be issued, and death cer- ificate sent to Bureau of Infectious Diseases as early IS possible the following morning for "O. K." and •eturn. If the next day is a Sunday or holiday, the iClephone operator should be requested to assign the ;ase in the morning to the proper district diaguosti- ian, certificate being sent to the Bureau of Infectious diseases for "O. K." on the following working day. Note : The clerk-in-charge of the Borough Office of he Bureau of Infectious Diseases inquires at the local ffice of the Bureau of Records each morning at 9:00 L. M. for such certificates.) (b) Where case has robably not been reported during life, a Sanitary Po- iceman should be immediately sent to placard prem- ies (the Bureau of Infectious Diseases will supply the ►ureau of Records with the necessary placards), 'hen proceed as in (a). B. — Procedure in Bureau of Infectious Diseases: Burial certificates must receive immediate atten- on and be returned to the Bureau of Records as >on as possible. (\i) Deaths in cases previously reported during —All deaths reported on any morjiing by death ■iiifix has occurred, are immediately removed and de- royed. METHODS OF DISINFECTION. I [Sec. 98. In making use of the various methods of siufection, the availability of each, and its inherent citations should be kept constantly in view, as for :ample. the fact that liquid disinfectants are only fective where the circumstances permit of their sys- matic application to all the surfaces to be treated, id that gaseous disinfectants are only of use for sur- ce disinfection. The fact is strongly insisted upon that for floors, loodwork and similar surfaces, soap, hot water and scrubbing brush, thoroughly used, are of greater liciency than either liquid or gaseous disinfectants, ; the latter are usually employed ; that boiling is the ;st method for treating all fabrics or articles not in- :red by such treatment, and that full aeration and :posure to sunlight must be regarded as of primary iportance in all cases. Inspectors and nurses constantly repeat the injunc- on that all articles use the Diagnosis and Serological Laboratories (cul- ire tubes, sputum jars, typhoid blood and urine, lalaria and Wassermann outfits). ISOLATION. Sec. 117. Sanatorium, sanitarium, day nursery, con- ilescent home for children, reformatory, training hool, boarding school, hospital, dispensary or insti- ition for the care or treatment of persons must rovide and maintain a suitable room or rooms for le temporary isolation of persons suffering from ifectious diseases. Cases of small-pox or those sus- cted of having this disease, and chicken-pox in iults must be held in isolation until seen by an in- )ector of the Department of Health, and, if necessary, le assistance of the police will be obtained to en- )rce this detention. Cases of diphtheria, scarlet fever and measles must jmain in the isolation room until seen by an inspec- )r of the Department of Health unless they reside » near the institution as to be able to return home ithout using public conveyances, and desire to do >. Such cases must have a private physician. Cases ' minor contagious diseases, such as chicken-pox in aildren, mumps, whooping cough and German measles lould not be admitted to the institution, but should e sent to their homes promptly. REMOVALS TO HOSPITALS. Sec. 118. Every case of small-pox will be removed y a Department of Health ambulance. Cases of 105 diphtheria, scarlet fever and measles will be removi by the Department of Health whenever necessary, condition of patient warrants. The representative ( the institution will caution patients ill of infectioi diseases against the use of public conveyances ai visiting places of public assembly. QUARANTINE. Sec. 119. (a) Hospitals: Wards in which coi tagious diseases develop will be quarantined by tt Department of Health as follows: Diphtheria— Quarantine is not required if all pi tients present or admitted are immunized and cu tures do not show diphtheria bacilli; otherwise fiv days. Scarlet Fever— Five daj'-s (children's wards onl: except where several cases occur in an adult ward). Measles— Fourteen days (children's wards only, es cept where several cases occur in an adult ward). Small-pox — ^Twenty-one days, with the exception o those exposed to small-pox: adult patients in quarar tine wards desiring to return to their homes may d< so if their names and home addresses are forwarder to the Department of Health. (b) Institutions: Dormitories or parts of buildini in which contagious diseases develop will be quaran tined as follows : Diphtheria— Five days (children's dormitory only except where several cases develop in an adult dormi' tory). Scarlet Fever— Five days (children's dormitorj only, except where several cases develop in an aduH dormitory). 106 Measles — Fourteen days (children's dormitory (Illy, except where several cases develop in an adult :lormitory) . Small-pox — Twenty-one days. Whenever contagious disease develops in more than lone dormitory at the same time, the entire institu- tion may be quarantined. [Note. — No cases may be admitted to or discharged from quarantined dormitory, or entire institution if quarantined, until quarantine is terminated by the Departiuent of Health. Children attending school will be excluded during the incubation period of the disease in question.] (c) When nurseries and day camps are quarantined no new cases may be admitted until quarantine is terminated by the Department of Health. CHIEF OF DIVISION. Sec. 120. The Chief of Division exercises general supervision over all matters pertaining to the work of his division throughout the city. (See Sec. 49.) OFFICE OF THE CHIEF OF DIVISION. SUPERVISION OF INSTITUTIONS. Sec. 121. Every institution is supplied with a plac- ard (hospitals Form 249 L, dispensaries Form 2-2~> L), to be posted, giving regulations regarding iiiMnngement of infectious diseases. A history card (I'orni — L) is kept for each institution, giving full iiifonnution, the name and address of the institution, fh.iractcr und ca])acity, names of officials and facil- ii i*'S for isolation. Every institution is revisited at 107 least once a year. A "subsequent visit" card fi] (Form — L) is kept, giving date of next visit b inspector and results of inspection. This card 3 forwarded to the inspector when visit is due an returned by him with proper entries after each visil From time to time, surveys are made regardin particular subjects (isolation facilities, etc.) ; th location and character of institutions are indicated oi large compo maps by vari-colored pins. Whenever a] institution is quarantined because of infectious dis ease, notices are sent to the institution, to the Stat Board of Charities, to the Department of Education to the Society for the Prevention of Cruelty to Chil dren and to the Borough Chief where the institution ii located. A weekly report by Boroughs is submittec (Form 222 L), giving the number of infectious disease! pending in and removed from each institution, anc the average daily time and number of visits of eact inspector. NOTIFICATION. Sec. 122. Every institution is supplied with ai Infectious Disease Journal (Form 9 LL), into which is copied from a blank (Form 280 L) every case of infectious disease occurring in the institution. This journal is divided into three sections, for: (a) Con- tagious diseases; cases of contagious diseases are immediately reported to the Borough Office by tele- phone and also by postal, (b) Tuberculosis; the De- partment of Health obtains reports of cases of Tuber- culosis by telephone at regular intervals, (c) Venereal diseases; the inspectors of the Division of Institu- tion Inspection call regularly and copy off the reports of cases of Venereal Diseases. 108 REGISTRATION. Sec. 123. In the Borough Olfice an envelope (Form ) J) is made out for each institution case and filed the current envelope case file. Cases are also re- >rted by the Borough Office to the proper Branch ffice on the daily report. At the Branch Office a eleton history card is made out and filed in the ;tive name file of the Branch Office. All such eases •e included in the weekly report of the Branch Efice, but are not visited. The Borough Office noti- 's the Branch Office of the discontinuance of the SB and skeleton history card above referred to is .'stroyed. A list of all cases of infectious diseases reported forwarded by the Borough Office to the Division of stitution Inspection. OFFICE OF DIVISION OF INSTITUTION IN- SPECTION. Sec. 124. A day book is kept of all cases of infec- 1>us diseases occurring in institutions, name of dis- "■'f, date reported, disposition, and date of termi- liou of each case, being recorded. A house card (Form 95 L) is kept for each in- iiition giving the above information concerning 1 y case of infectious disease reported. On removal < termination of cases remaining in institutions the "etor's history card (Form 20 J) is returned by • li to the Office of the Division of Institution Inspec- f n where facts are entered in the day book and on itistitution house card; the history is then for- M.led to the Borough Office to be placed in an ' velope in the terminated case file. 109 ASSIGNMENT OF CASES. Sec. 125. [Note. — Ou account of the long distant involved in the Boroughs of Queens and Richmoi, the district diagnosticians of those Boroughs respcl to calls from institutions, making diagnoses and ord- ing removal of cases to the Health Department Hj- pitals. Cases of infectious diseases remaining in ■ institutions of the said Boroughs are visited and I lowed up in the usual way by institution inspector] The City is divided into districts, to each of whi is assigned an institution inspector. Every insti.- tion case reported to the Borough Office is at oi? assigned by telephone to the proper inspector, details of the case, and later the inspector's rept being entered on assignment slip (Form 125 J), whi is forwarded to the Borough Office, thence to e Office of the Division of Institution Inspection £l finally returned to the Borough Ofiice to be filed in e envelope of the case. In addition to subsequent v t cards mentioned above, typhoid fever, epidemic c( bro-spinal meningitis and poliomyelitis histories, t of pending cases of diphtheria, scarlet fever il measles due for inspection and discharge, and reque a for special investigation (Form 178 J) are forward! to inspectors from the Division Office. DUTIES OF INSTITUTION INSPECTORS. Sec. 126. When a case is assigned to an inspecr of the Division of Institution Inspection, he at oe makes out a history (Form 20 J). He holds this 1'- tory, entering the results of all subsequent visits n the reverse of the card. When case is terminated y recovery, death or removal, the card is forwardedo the Office of the Division of Institution Inspect] i, 110 11 nd thence to the proper Borough Office where the History is filed in the envelope of the discontinued lase file for the particular disease. In cases for re- fiioval, the inspector makes out a removal slip (Form fO J). He informs the authorities of the institution if the destination of the case together with the ad- iress and telephone number of the hospital. After case of infectious disease is removed from a hos- ital or institution the inspector for that institu- ion is notified : he visits the institution at regular atervals and examines all persons exposed to the articular disease. If any new cases are found, he lOtifies the Borough Office by telephone, stating /hether or not the case is to be removed to the hos- iital, the authorities reporting the case to the De- lartment by postal card in the usual way. If a case emains at an institution, it is the duty of the in- pector to see that proper isolation is provided and laiutained. Frequent visits are made to examine all persons exposed and also to see that adequate quaran- ,ine facilities are provided. When the time prescribed ,y the Department of Health for the disease expires, jie patient is inspected and officially discharged if ■•ee from contagion. After the discharge of the last ise, the quarantine is ended at the termination of le incubation period of the disease in question, if new cases have developed. The development of Rrery new case requarantines the institution from lie date of the last onset of the disease. Children ittendlng public schools are excluded during the quar- •ntlne period. The inspectors are held responsible for ue accuracies of their diagnoses and at any time when ( Physlcian-in-charge of a Health Department Hos- iital questions or is dissatisfied with the diagnosis 111 of the case, they must, if requested, go to the I partmeiit Hospital and verify or change the origii diagnosis. In all cases where the clinical symptoi are so exceptional that a positive diagnosis cannot made, they are to see that the best possible arrant ments are made for the isolation of such cases. TL are to examine the case again on the following di. and then if they are not satisfied as to the diagnos, the case may be referred to the Borough Diagn( tician for his decision. In making their diagnoses, institution inspect^ must at all times respect the opinions of the visit! physicians in the various hospitals and institutic; and work in harmony with them as far as possib. Inspectors should maintain the friendliest relatio? with the authorities of the various institutions al keep them informed as to the regulations of t' Department of Health, and do all they can to ass in eliminating any contagious diseases that may occ , In every new case of scarlet fever, diphtheria • measles found in an institution, they must at once - port to the Borough Office by telephone and later ' postal card, the name, address, age of patient, al date of report of diagnosis. They must make outi history card (Form 20 J) for every case seen and n(? all subsequent visits with result3 on the reverse the card. The inspectors will administer diphthei antitoxin when requested by the authorities. In i eases of diphtheria, the immunization of persons ( posed is done by the inspectors and final cultures ; taken by them. Inspectors are responsible for the notification a I registration of Typhoid Fever, Cerebro-Spinal Men*- 112 Itis, Acute Poliomyelitis and Venereal Diseases in istitutions. Whenever an inspector finds in any istitution an unreported case of Typhoid Fever, 'erebro-Spinal Meningitis or Acute Poliomyelitis, he lis out a special report card (Form 18 J), giving ame of institution and disease, name, age and home ddress of the patient. Inspectors visit institutions /here records of cases of venereal disease are kept. 'rom these records they fill out a card (Form 191 L) or each case, giving disease, name, age and home ddress of the patient. These last two cards (Forms 8 J and 191 L) are forwarded by inspectors to the ffice of the Division of Institution of Inspection, nspectors make sure that the oflicial placard of the )epartment of Health is posted in every Institution nd that each one is supplied with and maintains an nfectious Disease Journal. They also make sure that pecial communications to institutions are posted. DIVISION OF TUBERCULOSIS. Sec. 127. The Division of Tuberculosis is charged vith the registration and sanitary supervision of all ■ases of pulmonary tuberculosis occurring in New fork City. ORGANIZATION. Sec. 128. (a) The Chief of Division exercises gen- eral supervision over all matters pertaining to the vork of his Division throughout the city. He is issisted by a Supervisor of Clinics. (b) Borough Offices. — (See Directory, Sec. 2, also 5ecs. 37 to 43.) (c) Branch Offices. — (See Directory, Sec. 2, also >ecs. 37 to 43.) 113 (d) Clinics and Clinic Districts. — Each Borough if divided into one or more tuberculosis clinic districts in each of which is a tuberculosis clinic, with its stafl of physicians and nurses. For location, hours ant boundaries of districts, see Directory and Maps, Sec 2. Each clinic cares for all patients from its owi district. In Manhattan a number of other clinics are maintained by the large general hospitals, aiu do their own district visiting. All of the tuberculosis clinics are united into an Association of Tuberculosis Clinics. (See Sec. 237.) (e) Clinic Auxiliaries. — Associations for rendering necessary charitable aid to patients of the Tubercu- losis Clinics. (f) Local Cli7iic Relief Committees. — Composed of the Physicians-in-charge, and representatives of the Auxiliaries and of the various charitable organiza- tions. (g) Tuhcrculosis Hospital Admission Bureau, 42G First Avenue, Manhattan. — For admission of all cases of pulmonary tuberculosis to hospitals, sanatoria, and preventoria for Children, Maintained jointly by the Department of Charities, the Department of Health, and Bellevue and Allied Hospitals. (h) Tuberculosis Day Camps. — For care of suitable cases living at home. Manhattan, foot of East 91st Street. Brooklyn, foot of Fulton Street. NOTIFICATION AND REGISTRATION. Sec. 129. These are described under Infectious Diseases. (Sec. 38.) Every case reported is acknowl- edged by card (Form 16 L). 114 PROCEDURE AT BRANCH OFFICES. 3ec. 130. At each Branch OflSce are filed the en- opes and case records of all cases of tuberculosis ing as the last address, one in the district. When les leave the districts, their records are trans- red to a central borough file, a transfer card orm SOL) being kept in the old file until word is i of their receipt at the new Branch Office, rhe Borough Office forwards to the proper branch ce a tracer (Form 266 L) in order to verify the V address. If the case is located the records are warded, a record being kept on a tally card (Form t L). If not found they are retained in the central rough file until the case is again located, a tally 'd (Form 263 L) being forwarded to the Branch ice of the district of last address, notifying it of ; facts. ^t each Branch Office the records are divided into many subsections as there are nurses' districts the district. Thus each nurse has her own cur- it record and house file. The system of regis- tion is as follows: CURRENT RECORD FILE. 5ec. 131. The cards in these files are divided into ) six recognized classes of cases — and are shifted >m one class to another aa occasion arises. (See er.) Each case has its record envelope (Form ) L) on which are entered: (1) the name, age, 8t address, sex, marital state, occupation, nationality, te of first report, first positive sputum examination any, annual record number and Borough, and by lom the case was first reported ; (2) all subsequent 115 changes of class, of address, or of attending phys cian. The dead cases are removed as they occi and forwarded to the Borough Office. Gases n( found at the address given and no subsequent repoi of which is received in one year, cases that have lei the city permanently, and recovered and non-tube culous cases are filed in a "discontinued" file. In the record envelope are filed the history care (Form 44 L) giving the information obtained by tl nurses and inspectors of the Department of Health ; to (a) the house; (b) the home, or rooms occupied t the patient or his family; (c) the family; (d) the ec nomic conditions; and (e) the patient — ^physical coi dition, precautions observed, treatment, etc. All lat( records of every kind (reports, nurses' visits, disinfe tions, admissions to hospitals, etc.) are entered, wit dates, on a later history card (Form 267 L). Tl history cards of cases under close sanitary supe vision by nurses are not filed, but are kept separal in the files for periodical review by the Physician-ii charge, who is expected to confer with each distri nurse attached to the Branch Office under his charg at least once a week regarding the cases of tube culosis under close supervision. Each nurse shou] be assigned a stated day and hour for confereiM each week. GENERAL ROUTINE. Sec. 132. On receipt of report of a case, from wha ever source, it is searched for in the record ai house files; if found to have been previously r ported, the facts given in the report are entered c the record envelope and also on the house card, if ne essary. If not in the record file, it may be found : the house index, where it may be under a diflferei 116 J differently spelled name. An envelope, primary his- 'y, and later history card, and (if a new house) house card are made out for every new case. The use card is filed. With the exception of those ses reported by private physicians and by non- (partment of Health tuberculosis clinics In Man- ttan, all cases, whether new or old, are then as- ;ned to nurses to visit (1) to obtain a history and ep under supervision or observation; (2) to order 5 necessary disinfection, or (3) to investigate com- lints. The record envelope remains in the current ?, and the primary and later history cards are given t to the nurse, to be returned the following day. 1 records of revisits are entered on the later his- ry card. A numerical daily tally is kept of the mber of cards given to and returned by each nurse. MONTHLY CENSUS. Sec, 133. On the last Friday of every month each strict nurse counts the number of envelopes in each the six classes of her file, corrects mistakes in filing, moves duplicates, etc., a record being kept in the anch Office. The figures are also sent to the clinics : use in their monthly report to the Association Tuberculosis Clinics. LILY REPORT TO HOSPITAL ADMISSION BUREAU. Sec. 134. All changes of address, departure from J city, etc., of cases that have ever been in a tuber- losis hospital, are reported daily (Form 153 L) to i Hospital Admission Bureau. 117 CLASSIFICATION OF OASES. Sec. 135. The procedure varies somewhat with t character of the case. The cases in the current i are grouped in six classes as follows: (1) Unc care of private physicians. (2) Under care of n< Department clinics doing their own nursing. ( Cases in hospital. (4) Cases in sanatoria and ( of town temporarily. (5) Cases not found at addr( given. (6) Cases at home, and not under a phj clan's care. CLASS I. CASES UNDER THE CARE OF PRIVA'. PHYSICIANS. Sec. 136. These cases are given to the nurse 1 "information only," and the locality visited to asc tain if there is a house at the address given, and character: i. e, private one-family house, teneme etc. Further information regarding these cases obtained from the physician on a special card, oi every two months, as follows: At the close of ev( second month a new physicians' information tub culosis card (140 L) and an envelope addressed the physician are filled out at the Branch Offi for every private case in the current index, and f warded to the Borough Office. From there they i mailed to the physician with a stamped envelope ] return. When returned, the physician's card is fil in the central name file in the Borough Office, a the facts forwarded to the Branch Office, where tt are entered on the record envelope of the case. Shoi the card not be returned by the physician witl fifteen days, the Branch Office nurse telephones i physician to obtain the necessary information. Faili on the part of private physicians to respond on 1 118 ard will be followed by a visit from the Department iiirse. If the patient is no longer under his care, a Liu'se visits the premises and takes appropriate action. Vhen a nurse reports that a patient is under the care if a private physician, he is requested by letter (Form 15 L) to forward a certificate to that effect (Form 14 L). JLASS II A. CASES REPOR^^ED BY NON- DEPARTMENT TUBERCULOSIS CLINICS IN THEIR OWN DISTRICT (MANHATTAN ONLY). Sec. 137. These cases are not assigned to Depart- oent district nurses except on request. The envelopes if such cases are kept in the current file under Clinic," and comparison made with the records of the ilinic at stated intervals. On the first visit to the home f each new clinic case the non-Department clinic furse fills in blue card (Form 149 L) with information bout house conditions required for house file in the Jranch Office. These cards as completed are turned ver to the district nurse, who forwards them to the {ranch Office. If the case is not found at the address iven, the cards are shifted from "clinic" to "not ound" section of the current file. The clinic may request that district nurses visit its ases (1) to order disinfection; (2) to induce patient 3 return to clinic; (3) to recommend forcible re- loval. When a complaint regarding one of this class of linic cases is received at the Branch Office, the clinic 3 always consulted before patient is visited. When ases of tuberculosis are discharged by the clinic for on-attendance or any other reason, they come under 119 the care of the district nurses and become "at home cases. (See Sec. 141.) [Note. — When a clinic reports a case as living i: another district, and unless the report states tha the first clinic wishes to keep the case under treat ment, a district nurse visits the patient at once, an urges the patient to attend the proper clinic patient does not report at second clinic within te daj^s, he is revisited and again urged to attend clini If he refuses to do so, he is then classified as an "a home" case. If patient does report at clinic, he treated as a clinic patient.] CLASS II B. CASES ATTENDING OTHER CLINICS. The name, address and clinic attended of ever patient attending a clinic outside of his distri< should be entered on a "transfer and receipt" car (Form SOL) and filed among the clinic cases in tt Branch Ofiice of the clinic attended. Such cases ai to be reported to the clinic of the district of res dence and recorded in the name file of said clini together with the name of the clinic actually attend© Should such a patient later attend the clinic of h district, the name file will make known that a clin history is already on file in some other clinic, ai the same can then be sent for. ii CLASS III. CASES ADMITTED TOi HOSPITA Sec. 138. When word is received from the Borou? Office that a case in the district has entered a ho pital, the name of hospital and date of admission a; entered on the record envelope and the case reclassifii in the index. The later history card is assigned to tl 120 arse, who visits the premises and orders the neces- iry disinfection. This applies to all clinic as well s iit home cases. A "home condition" card (Form i4L), stating wliether patient should be allowed to ^tnrn home, is filled out by the nurse for every ise, and mailed direct from the Branch Office to the [ospital Admission Bureau. The same procedure is allowed in dead cases, except that the case is re- loved from current file. LASS IV. CASES LEAVING CITY TEMPORARILY OR ENTERING SANATORIA. Sec. 139. Here the procedure is the same as in ases entering hospital, the cases being subdivided into a) out of town; and (b) in sanatoria. CLASS V. CASES NOT FOUND AT ADDRESS GIVEN. Sec. 140. Every effort is made by the district urse to locate the patient. Should this be impossible, iie reason is given, e. g., "no house at that address" ; only a friend's address, never lived here and where- bouts not known" ; "never heard of at that address" ; lived here months or years ago," etc. If informed that patient is dead, the nurse uses very effort to learn v/here and when patient died. l11 cases reported "not found" are reinvestigated by second nurse. W^hen a "not found" case is re- orted from another address in another district, that act must be reported to the original Branch Office y the Borough Office, in order that original records lay be transferred. At the end of one year the ecords of "not found" cases not subsequently re- orted are removed from the current to the discon- tnued file. 121 CLASS VI. "AT HOME" CASES. Sec. 141. Under this head are included cases re- ported by general dispensaries, those discharged from hospitals, sanatoria and tuberculosis clinics, those reported by private physicians with request that they be visited, etc. [All cases discharged from Riverside Hospital, in which the home or other con- ditions have been previously reported as unsatisfac- tory and retention of the patient is recommended, are to be reinvestigated at once. The return of the patient to Riverside, by force if necessary, is to be recommended if such action is warranted by the result of the investigation. Such discharged cases are reported by letter direct from the Admission Bureau to the Branch Office.] The patients are, of course, urged to attend the tuberculosis clinic of the district, and should they do so they become clinic cases. Until the sanitary conditions are satisfactory, and instruc-^ tions are obeyed, each case is visited every few days ; thereafter, at least once every two months. The record envelopes and the tally index in the Branch Of- fice call attention to any case being overlooked. A new later history card (Form 267 L) is assigned to the district nurse, and returned the following day. All necessary facts are then entered on house card. If sanitary conditions are satisfactory, the later history card is filed in the record envelope in the current in- dex. If case is kept under supervision, it is kept in the front of nurse's section of the index. DEAD CASES. Sec. 142. All deaths from tuberculosis are reported to the Borough Office by the Bureau of Records (see Sec, 65), and thence to the proper Branch Office on 122 ]y report. The record envelope is stamped "Dead," 1 imless patient died in a hospital, the later history (1 is assigned to the district nurse to order the I essary disinfection, etc. On receipt of nurse's r )ort that disinfection has been attended to, the erelope with the liistory card is removed from the creiit file, all facts entered on the record envelope i bouse card, and the envelope and history cards I i t■o^^yarded to the Branch Office. A list of the ciths is forwarded at once to the Hospital Admis- & n Bureau. A record is kept of the number t previously unreported dead cases on daily tally 5 9et. In all previously unreported cases where ti physician signing the death certificate had been i attendance one week or more, a letter (Form 25 L) i sent by the Physician-in-charge to said attending tysician calling his attention to the violation of the 'nitary Code and requesting an explanation. Should t. answer be received within two weeks to two such I ters, a third letter is forwarded to the Executive Ifice, with recommendation that it be delivered by a (Qitary policeman, demanding an explanation on I in of prosecution. RECOVERED CASES. Sec. 143. Before a case can be removed from the irrent tuberculosis files of the Department, as ap- I I ently arrested, all constitutional symptoms and ] ectoration with tubercle bacilli must have been -ent for a period of three months, the physical /! s to be those of a healed lesion. On receipt of attending physician's certificate of this condition "orm 87 L) the Borough Office is notified to remove sf; from its own and Branch Office files. 123 CASES LEAVING THE CITY PERMANENTLY. Sec. 144. As in dead cases, these cases are at one assigned to the district nurse to order the necessar; disinfection, and the record envelope removed froi the current file and placed in the discontinued file. UNDIAGNOSED CLINIC CASES. Sec. 145. When patients under observation in th Tuberculosis Clinics fail to attend until a diagnosi can be made, they are visited by a nurse and urgei to return. Should they fail to do this they are vij ited by the attending physician, who endeavors t arrive at a diagnosis. SCPIOOL CHILDREN. Sec. 146. Each Borough Office records the numbe of reported cases and deaths from tuberculosis ii children from 0-5 and 5-16 years of age. All case and deaths of children of school age are reporte( from the Branch Office to the Executive Office (Forr 126 L), where further investigation is made as t< exclusion from school. All cases of children of schoo age, with tubercle bacilli in the sputum, are reporte( by the Diagnosis Laboratory to the Executive Office Children whose sputum has shown the presence o tubercle bacilli within two months are not permittee to attend school. If they are, or have been, attend ing public schools, the Bureau of Child Hygiene ii requested to exclude them, a special card (Form 83 L; being used for that purpose. In cases attending private or parochial schools th< same procedure is followed. In cases under the care of private physicians, in formation is obtained from the physician as to resuli 124 ' private sputum examination and location of school tended. A specimen of sputum is also asked for. Cases suffering from tuberculosis, whose sputum jes not contain tubercle bacilli or cannot be exam- led, are referred to the Bureau of Child Hy- ene for exclusion only when there are physical gns of disease, the child is in poor condition and le parent or guardian consents. Where the child admitted to or discharged from a day camp, the tacher at the camp is expected to notify the school iithorities to transfer the child from or to its reg- lar public school, as the case may be. - When the patient improves and examination of vo consecutive specimens of sputum fails to show le presence of tubercle bacilli, the Bureau of Child 3'giene is requested to permit the child to return to •hool. The Bureau of Child Hygiene is furnished period- ally with information, obtained from the district iberculosis nurses, regarding the whereabouts of rery case of tuberculosis excluded from school, if iider medical care, and by whom. The nurses make rery effort to induce all suitable cases to enter a ay camp, or an institution. A8ES REPORTED AS LIVING IN OTHER BOROUGHS. Sec. 147. These are at once reported to the Bor- igh Office of the Borough in which they live. When patient moves to a definite address in another orongh, the original records are forwarded to that ^jrough Office through the Executive Office of the ureau. 125 SUSPECTED CASES AND COMPLAINTS. f Sec. 148. All cases reported by lay individuals and organizations, and nurses, are classed as "suspected" cases, and are referred by the Borough Office to the proper Branch Office, where they are first assigned to the district nurse for investigation. She forwards a history (Form 44 L), and endeavors to induce the patient, if not under a physician's care, to attend her clinic ; failing in that she obtains a specimen of sputum. If she cannot do this, the case is assigned to a clinic physician. Should there be a physician in attendance who has failed to report the case, he is communicated with by telephone or letter. If not a case of tuberculosis, it is classed as "no case" and not entered in current record file, history card being filed in Branch Office. All complaints by citizens (as to spitting, necessity for hospital treat ment, etc.) are first investigated by a tuberculosis nurse, who submits a history card with report. If there is a physician in attendance, he is commu nicated with and requested to see that the nuisance is abated if one exists. Complaints by nurses or physicians as to unsanitary conditions and recom mending inspection are forwarded on special blank (Form 3L). The report is journalized, approved by Physician-in-charge, and forwarded to Executive Office. If a tenement house, the complaint goes to Tenement House Department; if a one or two-family house, to the Sanitary Bureau of the Department. All reports of cases, either to the Executive Office, or to private physicians or outside organizations, should be made on the card furnished for that pur- pose (Form 87 L). 126 1 NVESTIGATION OF SUSPECTED CASES OF TUBERCULOSIS AND COMPLAINTS. lec. 149. All suspected cases of tuberculosis that ;\1 not or cannot visit a clinic, and in which the itrict nurse cannot obtain a specimen of sputum, I examined at their homes by a clinic physician. E?se cases are reported to the Department by lay ) anizations, citizens, district nurses, inspectors of ) er city departments, etc. The physician submits 1 ull report of the case on a history clinic diagram d (Form 211 L). ^ ill suspected cases of tuberculosis (permanent cen- i cases, special complaints, etc.), if not on record ithe Branch Office, are to be assigned immediately a clinic physician for investigation, and a report Lsto be forwarded at once to the Executive Office. le visiting physician must examine the patient f^enever possible, and not rest content with referring ba, or her, to the clinic. Should disinfection be D-essary, a nurse should be sent. [ICOMMENDATIONS FOR CHARITABLE AID. 5ec. 150. When made by district nurses in districts r ere there are no local relief committees, these are ^warded direct from the Branch Office by double r-^tiil (Form 81 L) to the proper Association. A r:ord (Form 42 L) is kept of every reference, and \ien the return postal is received and entered on r.ord of case, it is filed behind tally card. At in- tvals a second postal is sent for each case in which 1 reply has been received. 127 RECOMMENDATIONS FOR HOSPITAL CARE. Sec. X51. When these are received on nurses' ( physicians' histories, duplicate reference cards (Forj 1Y4L) are forwarded to the Hospital Admissio Bureau. Applications for sanatoria, the Preventorium, ( Department Day Camps, are made only by the tube culosis clinic of the district. SUPERVISION OF FAMILIES OF CASES IN HOSPITAL. Sec. 152. When patients in a hospital have famili* remaining at address from which patient enters ho pital, those families are visited at intervals by di trict nurses to obtain information for Hospit; Admission Bureau as to whether patient should 1 allowed to return home from the hospital. SANITARY SUPERVISION OF TUBERCULOSi; DISINFECTION. Sec. 153. Every case reported as having been te minated at a given address (removals, previous a< dresses of new cases, deaths, admissions to hospital etc.) is at once assigned to the district nurse, wl recommends the necessary renovation, fumigation an disinfection of the rooms, such recommendations beii: noted on later history card. KINDS OF DISINFECTION ORDERED. Sec. 154. According to the conditions of the preu ises the nurse may recommend: (a) that nothing t done ; this is most exceptional, obtaining only 1 very recently renovated apartments and those whei the patient only spent one or two nights on the preu 128 ^s- if the premises are in good condition and the iit'nm examhiation is negative, a thorough cleansing )cl airing is sufficient; (b) that the whole apartment the room occupied by the patient be fumigated with rmaldehyde. (This is to be ordered only when reno- tion cannot be performed, because of the family maining on the premises, etc.) ; (c) that the pa- int's room be thoroughly renovated; the walls ashed and rekalsomined, repapered or repainted, and e woodwork and floors be washed and repainted; 1) that the whole apartment be renovated. RENOVATION PROCEDURE. Sec 155. When renovation is required, a Renova- on Request (Form 157 L) is left by a nurse with le janitor. A re-inspection is to be made in ten days. If work IS not been begun, and the indications are that will not be, the nurse will fill out a Renovation omplaint (Form 48 L). This complaint is to be )rwarded through official channels to the Superin- >ndent of Nurses. The Superintendent of Nurses ob- lins from the Complaint Clerk of the Borough a umber, which is written on the complaint, and said omplaint is then forwarded to the Chief of the Di- ision of Tuberculosis. Upon his approval, the com- laint is forwarded to the Bureau of General Ad- ilnistration for record, and for the issuance of a :enovation Notice (Form 14 E). A copy of the Reno- ation Notice, when issued, is returned to the Superm- endent of Nurses, to be forwarded by her, through fficial channels to the proper Branch Office. The rf-mises are Inspected eight days after the Renova- ion Notice is issued. If the Renovation Notice has 129 not been complied with, or work is not progress! endorsement to that effect is entered upon the Not by the nurse, and it is returned through oflScial ch nels to the Superintendent of Nurses, who forwai it directly to the office of the Corporation Couni Upon its receipt, by the Corporation Counsel, a Oo sel's Notice (Form 5 D) is sent. After forty-elj hours, the Renovation Notice is returned directly the Superintendent of Nurses, who forwards it throi official channels to the Branch Office for re-inspecti by a nurse. If the notice has not been complied w or work is not progressing, it is returned to the Oh of Division and referred by him to the Lieutenant- Command of the Health Squad, who details a patr man to warn the person against whom the notice is sued. If, upon re-inspection by a patrolman of 1 Sanitary Squad, it is found that work has not co menced, a summons is issued by him. Applications 1 extension of time or relief from orders are to be ma by the applicant, in proper form, and if appro'v by the Chief of the Tuberculosis Division, are to so endorsed and forwarded to the Bureau of Genei Administration. Renovation Notices, when compli with, are to be so endorsed and forwarded, throu official channels, to the Bureau of General Admin tration, for distribution to the proper Borough Offi( for filing. SCRUBBING OF FLOORS AND WOODWORK. Sec. 156. In all instances where this is the or procedure recommended by the nurse, she must ma every effort to induce the janitor to perform the wo voluntarily without the issuance of a notice. Shou she fail to obtain this result, she must forward 130 eport on the regular renovation blank (Form 48 L), laking a report and recommendation in a manner xactly similar to a case whefe a notice would be isned, except that after the recommendation the ollowing statement is to be made: "Inasmuch as I ,ave been unable to obtain voluntary compliance vrith liis recommendation, I would further recommend that he scrubbing of floors and woodwork be enforced y the Sanitary Police." PLACARDS. Sec. 157. When there is reason to believe that reno- ration will be evaded, and in every case where the remises are vacated by the death or removal of the latient and renovation has been ordered, the nurse ,aust placard the door of the apartments with a poster Form 113 L). A duplicate placard is to be forwarded to the yhief of Division. The Lieutenant-in-Command of he Health Squad is then requested (Form 52 L) to nstruct a sanitary policeman to visit the premises, e-placard same if original placard has been removed, md warn the tenant and janitor not to remove same. Vhen a nurse removes a placard, she leaves a notice 'Form 55 L) for the policeman. VOLUNTARY RENOVATIONS. Sec. 158. When owner or agent voluntarily per- orms renovation, that fact is reported and the nurse evisits the house at short intervals until work is [one, a record being kept of the number of such vol- intary renovations. 131 CLEANERS AND SCRUBWOMEN. Sec. 159. A staff of cleaners or scrubwomen hi been established to wash and clean the floors an woodwork of premises occupied by persons sufferii from pulmonary tuberculosis. These cleaners ai attached to the various clinics aud Branch Ofiice and their outside work is assigned to them by tl Physician-in-charge. The district nurse meets the cleaner on the prec ises, gives her the necessary instructions, sees thj the work is performed properly, and submits a repo: of the same. Such cleaning is ordered by the nurs in cases where the family either will not or cannc do it, and where, for any reason, the patient shoul not be removed to a hospital. FORCIBLE REMOVAL OF CASES OF PUL- MONARY TUBERCULOSIS. Sec. 160. Recommendation that a given case < pulmonary tuberculosis be removed to a hospital, I force if necessary, on the ground that the patiei is a menace to the health of others, is made by tl district nurse, all complaints being assigned to h( for investigation. Before recommending such forcib removal of a case of pulmonary tuberculosis, tl nurse endeavors to obtain the patient's consent enter a hospital. The grounds for the forcible r moval to hospital of a case of pulmonary tuberculos are: (a) that the patient's sputum contains tuberc bacilli; (b) that the patient either will not or cann observe the necessary precautions as to disposal sputum; and (c) that others (especially children) a 132 posed to infection. Should the nurse find that all above conditions exist, the Physician-in-charge bmits a special report (Form 64 L), recommending » removal of the patient. This is forwarded to the ief of Division. When approved by him later, and len the Hospital Admission Bureau arranges for a ancy at Riverside Hospital, the original papers are •warded to the hospital, to be returned thence with ^tort, on discharge or death of patient. The Physi- :■ n-in-charge makes all necessary arrangements. He :;t telephones to the office of the Borough OflSce for 1 policeman to meet him at the patient's home. : then visits patient,- and if the latter is still on ; premises leaves him or her in care of the police- m while he telephones direct to the Borough Office ) the Department for an ambulance. Returning to . premises, he there awaits the arrival of the ambu- ice. If in his opinion the patient is in a dying jidition, he suspends removal. Vhen it is desired that patients who have entered ^erside Hospital voluntarily, be detained there, a •lommendation to that effect is forwarded to the Urd of Health for its approval. UPERVISION OF CASES AT THEIR HOMES. GENERAL PROCEDURE. ec. 161. The first duty of the tuberculosis district ! of the Department is to exercise the necessary iry supervision over the cases of pulmonary ulosis living in her district. Almost the first ion asked, when making a visit to a new case, I other the patient is under the continued care I private physician; if so, his name and address 133 are obtained. In tracing cases on first visit, or, unable to obtain admission, when making a revii no messages are left with neighbors. The reason the nurse's visit (i. e., that there is a consumpt on the premises) is only to be given to the fan; and not in the presence of visitors or strangers, possible. The nurse furnishes the Departm^t w prompt, accurate and sufficiently frequent reports to where the patient is, his general condition, tempe ture and pulse, whether the necessary precautions being observed (sputum, etc.), if he is receiving m< cal care and where, the nature and condition of house and rooms in which he lives, the number in family, etc. She calls attention to any faulty coi tions and recommends the steps to be taken for tl betterment. General unsanitary conditions are repi ed and the case is kept under sanitary supervis and visited every few days until faulty conditi are corrected or the recommendations carried out. necessary, she may recommend that a physician ( CIRCULAR OF INSTRUCTION. Sec. 162. The following circulars of instruction the language spoken by the patient, are given to patient or the family: 1 — Folders of General Information Regarding ( sumption. Printed in four languages. 2 — Folders of Advice to Patients, each printed in I lish and one other language; three language -Cards of Advice Regarding Sweeping and Dust! In English and one other language; three guages. 134 I >ESCRIPTION OF NURSES' WORK IN HOMES. Sec. 163. Any other suspicious cases of tuberculo- s among the family and neighbors are traced and jported. Should the patient be a child attending hool, the nurse reports whether or not he or she lould be excluded from school. The welfare of [ly sickly or anaemic children is looked after and ley are protected against infection as far as possible, necessary their admission to a fresh air school, day camp or Preventorium is recommended. If 18 rooms are very dirty and the occupants cannot will not clean them, the nurse forwards a recom- endation to the Branch Office that a cleaner be sent y the Department (see Sec. 159). If the patient is at work, the nurse reports as to hether his work is harmful to him, his presence menace to his fellow workmen, or if he is likely to )read infection to the public (bakers, handlers of odstuffs, cooks, laundresses, etc.). If any work is me at the home, the nurse makes sure that no one endangered thereby. If the case is suitable for hospital or sanatorium .re, she endeavors to induce the patient to enter an stitution voluntarily, and submits a recommendation that effect. All the above information is submitted ' the nurse on the later history card (Form 44 L). The patient's temperature and pulse must be taken every visit, or the reason stated for not doing so. lis applies especially to observation cases. The district nurses may be called on to deliver [mission cards to tuberculosis hospitals (Form 32 L) patients, and instruct them how best to reach the tgpital, and as to outfit required (Form 227 L), etc. 135 DUTIES OF DISTRICT NURSES IN CLINICS ^ Sec. 164. In all tuberculosis clinics except non Department clinics in Manhattan, which do their owi ^ district nursing, the district nurses devote a certah portion of their time to work In their clinic. Ii addition to their regular routine clinic duties, thej meet all the clinic patients from their own sub-dis trict, who have been instructed to return on thosi days. They thus familiarize themselves with the med ical aspect of their cases, and their presence tendi (f to promote friendly relations between the clinic, th( patients and themselves. They also call the attendinj pliysicians' attention to anything specially worthy o note regarding the patients and their home surround ings. HISTORY CARD. Sec. 165. This card (Form 44 L) gives a descrip tion of the house, the rooms, the family, the financia conditions, the physical condition of the patient, pre cautions observed, instructions given, and any recom ia mendations. One of these cards is given out for every ne\ assignment (including dead cases, those removed t hospital or sanatoria, etc., etc.). Very often patient will give the address of a friend or relative with whor they have never lived. The history card need not b filled out in such cases, unless the patient be seer A new card is assigned whenever patients chang their address, return home after a considerable at sence, or when conditions at the home have changec In many instances only the description of the hous can be given, as the rooms cannot be located. Bu 136 7en tliis scanty information is important, as it is squired for the house file at the Branch Office. This istory card is also used by a number of the non- lepartment clinics of Manhattan Association of Tu- Brculosis Clinics. When cases under care of private physicians or on-Department tuberculosis clinics are visited to or- er disinfection, etc., only the house history, location f rooms, how long the family has been in rooms, revious address, and name and address of physician r clinic caring for patient are entered on the card. ;ut when such cases are visited on complaint, a full istory is taken. The Borough case number and year of old cases re always entered in the proper space in the upper ight hand corner of the card. DISTRICT WORK OF CLINIC PHYSICIANS. Sec. IGO. As stated in Section 149, the clinic physi- ians do district visiting in addition to their clinic rork. The assignments are made by the Physician- i-charge, and all reports submitted on a clinic iagram card (Form 211 L). A record of the visits J kept in the Branch Office, and given in its weekly eport. TUBERCULOUS CHILDREN. Sec. 167. Cases of pulmonary tuberculosis in chil- ren under sixteen years of age, in which the attend- ig physician will not certify in writing that patient an safely attend school, where the patients will ot or cannot visit the nearest Department Tuber- ulosis Clinic, or where a specimen of sputum is 137 refused, may be assigned to a clinic physician for in vestigation and report. In investigating cases re ported by tuberculosis clinics for exclusion or re admission to school, the physician will consult witl and obtain all information possible from the clinii before visiting the child. VISITS TO LODGING HOUSE PATIENTS. Sec. 168. Monthly visits to patients living in lodg iug houses are made by the clinic physicians on re quest of the district nurse. Lodging houses and Mills hotels are notified (Forn — L) when a case of tuberculosis is reported fron that address, and are required to inform the Depart ment of Health (Form — L) of the departure oi such cases. VISITS TO CLINIC PATIENTS. Sec. 1G9. The tuberculosis clinics sometimes sem a physician to visit a clinic patient who is too 11 to attend the clinic. A clinic physician visits th( patient, prescribes if necessary and forwards a repor recommending suitable action (usually removal t< hospital). But he does not continue to render medica service at the home. RECOVERED CASES. Sec. 170. When notice is received that a given cas< of tuberculosis has recovered, and no physician's cer tificate is forwarded, the case may be assigned t( the clinic physician to visit and make a physica examination. 138 I FORMATION FOR THE PUBLIC REGARDING THE SUPERVISION OF TUBERCULOSIS. CIRCULARS. Sec. 171. The following circulars, etc., are issued I tlie Department, through its nurses, through drug fi>res acting as supply stations, and through stereop- ton and traveling tuberculosis exhibits, to persons tiering from tuberculosis and their families, to phy- i ians and to others interested : Circular of Infor- iition Regarding Measures Adopted for the Sanitary ; per vision of Tuberculosis (Form 66 L). Circular ] garding Importance of Early Diagnosis of Tuber- (iosis (Form 75 L). "Sweeping and Dusting," in ;iglish and German (Form 176 L) ; English and Ital- i (Form 177 L), and English and Yiddish (Form ;jL). Circular of Information Regarding Consump- in, in English (Form 231 L); German (Form !0 L) ; Italian (Form 238 L) ; Yiddish (Form 241 L) ; :»beuiian (Form 239 L); Finnish (Form 107 L) ; jlisb (Form 133 L) ; Slovak (Form 134 L); Ru- enian (Form 13.5 L); Sv/edish (Form 236 L); Ar- iiiian (Form SOL); Spanish (Form 29 L), and iinese (Form 162 L). Advice for Patients in two iigiiages : English-German (Form 139 L) ; English- niiau (Form 155 L), and English- Yiddish (Form 7L), Consumption Cures (Form 229 L). Con- niption Cures (in Italian) (Form 72 L). Hand lok of Help for Consumptives (Form 2L). What )U Should Know About Tuberculosis (Form 123 L). iljii'culosis Catechism for Children (Form 246 L). pgistration and Sanitary Supervision of Pulmonary Uberculosis (monograph No. 1). Tuberculosis linics and Day Camps (monograph No. 2). Metal 139 and paper signs warning the public against spittit and "Anti- Spitting Pads" (Form 130 L). Leaflet R garding Reporting of Tuberculosis (Form 9L). MOVING PICTURE AND STEREOPTICON EXH BITIONS. Sec. 172. These are given at night in the publ parks throughout the summer, notices of such exh bitious being distributed by nurses, through drr stores, etc. These notices are printed in English an other languages, as follows: English (Form 12 L) Yiddish (Form 41 L), and Italian (Form 46 L). Pla ards (Form 209 L) are posted throughout the city. CARE OF THE DEPARTMENT'S TUBERCULOSI PATIENTS. THE TUBERCULOSIS HOSPITAL ADMISSION BUREAU. Sec. 173. Located at 426 First Avenue, Manhattai in the immediate neighborhood of the Department c Charities, Bellevue Hospital, the large medical school and a number of dispensaries. Telephone 8667 Mac ison Square. This Bureau has been established b mutual agreement of the Department of Charitief the Department of Health, and of Bellevue and Allie Hospitals. The staff of the Manhattan Bureau consist of a Physician-in-charge ; a Clerk-in-charge and Exaa iners, detailed from the Department of Charities; A1 tending Physicians, detailed from the Department o Charities and Health ; a Dentist ; Nurses ; Hospital ani 140 her Clerks. A special letterhead (Form 19 L) and ivelope* (Forms 10, 17 and 20 L) are used. The bysician-in-charge keeps a diary of current events. A weekly report (Form 190 L) is submitted to the 'ureau of Infectious Diseases and to the Department -; Charities. s^STITUTIONS ADMITTING THROUGH BUREAU. Sec. 174. Tuberculosis institutions to which patients e admitted through Bureau : (1) General tuberculosis hospitals maintained rectly by the City Government (Metropolitan, River- de and Sea View). (2) General tuberculosis hospitals maintained in- reetly by subsidy [Seton, St. Joseph's, St. Vincent's Id Montefiore Home and Montefiore Country Home Bedford Hills Sanatorium)]. (3) Reception hospital for patients needing im- ediate care: (Bellevue.) Cases are admitted on •rsoual application or are referred by Admission ireau when direct application is made too late for I mission to a general hospital the same day. The Iniission Bureau places all such cases in other hos- tels as soon as possible, except those which the )spital authorities wish to retain. (4) Sanatoria (Otisville and New York State Hos- t;il for Incipient Tuberculosis at Ray Brook). f "O Tuberculosis Preventorium for Children, Farm- i,Ml;ile, New Jersey; Tuberculosis Preventorium at 1 11 net, New York. (*'<) The Manhattan and Brooklyn Day Camps of (' Department of Health. [See section 191]. 141 APPLICATIONS FOR ADMISSION. Sec. 175. All applications for institution care whether made to the Department of Charities, Belle vue and Allied Hospitals, the Department of Health charitable organizations, tuberculosis clinics or gen eral dispensaries, etc., are referred, either directl; or by letter or telephone, to the Admission Bureau When by reason of weakness or other sufficient caus' the patient cannot present himself in person at th Bureau, he is referred for examination to the tuber culosis clinic of that district of New York City ii which he resides. If the patient is bed-ridden, a nurs or clinic physician visits the house and forwards i report to the Admission Bureau. Clinics in referrini a case for admission to hospital forward a specla history card (Form 174 L). SYSTEM OF REGISTRATION. Sec. 176. The hours of the Bureau are from 9 A. IS! to 5 P. M. Complete information regarding all inst: tution cases of pulmonary tuberculosis in New Yor City is kept on file, a record envelope (Form 109 L] record card (Form 110 L), and clinical record (Fori 174 L) being used for that purpose. On the recor envelope are entered: (1) all necessary facts r( garding the patient for identification, case numbe; etc. ; (2) the date of application for institution can when and where admitted, reports from the hospita date of death or discharge, etc. ; (3) similar data r( garding all subsequent applications. In the enveloi is filed the record card of the case, and the repoi of the district nurse as to whether patient should I allowed to return home. Information regarding an given case is thus obtainable at a moment's notice. 142 3 EXAMINATION AT ADMISSION BUREAU. 5ec. 177. If the patient applies in person and no rord of his or her physical condition is on file, a jf'sical examination is made. At the same time the ye is assigned to an examiner to visit the patient's me and report on social and financial conditions ; re. These examiners are detailed from the De- ::*tment of Charities. (See Sec. 179.) Transients il those unsuited for hospital care are referred for - ther treatment to the tuberculosis clinic of the Itrict in which they reside. 'atients are notified by card (Form 128 L) to call I Bureau. VISITS BY PHYSICIANS FOR DIAGNOSIS. pec. 178. If the applicant cannot visit the Admis- tt Bureau in person, he is visited and examined by of the clinic physicians, who forwards clinical ord (Form 174 L) to the Admission Bureau. These rsicians have received special training in the gnosis of pulmonary tuberculosis. NVESTIGATION OF HOME AND FINANCIAL CONDITIONS. 5ec. 179. By the Bureau. On receipt of applica- tt at the Admission Bureau, the case is at once igned to an examiner of the Bureau to visit and ort on the home and financial conditions. She [uires into the conditions of the house, the home the family; whether overcrowding exists; if lers (especially children) are exposed to infection; cunt and disposal of expectoration; general con- ion of the patient, legal residence, etc. Full in- 143 formation as to tlie economic conditions is also - tained — amount of rent paid and other expenditur, number to be supported, the earnings of each me ber of the family, and what aid they are receivi from other sources. All these facts are reporu on a special card (Form 110 L). This is forward to the Admission Bureau. Such an investigation the social conditions, as described above, is made i every instance. Physical examination may > omitted at the discretion of the Bureau, if a reci record is on file. ADMISSION TO HOSPITAL. Sec. 180. If found suitable the case is then i- mitted to the most suitable institution, an admiss i card being at once delivered by a district nurse, y\ also gives the patient full instructions as to how reach the institution, outfit needed, visiting hoi for the family, etc. When necessary an ambulai or carriage is provided. If there are no vacanci, the name of the patient is placed on a general wj- ing list, a special card (Form 20.3 L) being used. HOME CONDITIONS AFTER ADMISSION. Sec. 181. In every case admitted to a hospital r sanatorium, a "home conditions" card (Form 144 i is forwarded to the Bureau from the Branch Ofl of the district in which the patient lives. If the patient is unknown at the address giv , "not found" is entered on the card. Such cards ; assigned to a nurse, who visits the hospital and asc- tains the correct address. The card is then returil to the Branch Office for further investigation. 144 IFPERVISION OF FAMILY WHILE PATIENT IS IN HOSPITAL. ^ec. 182. District nurses of tlie Department of I'alth visit the Families of patients in hospital at uiilar intervals, to obtain correct and up-to-date in- ■mation as to whether it is best for the patient to kirn home. ^vEPORTS FROM INSTITUTIONS REGARDING I THEIR PATIENTS. Sec. 183. A telephone report is obtained dalljr by ilmission Bureau from all institutions, of the numer- jil census (male or female) of patients, and the 111 name and address of all patients admitted, dis- arged, transferred, or dead, during the previous :enty-four hours, and the names of all patients ishing to be discharged (Form 209 L). The num- r of vacancies is also obtained ( Form 63 L ) . Pri- .te sanatoria report admissions, discharges and laths by mail (Form 69 L), and state whether pa- snts are to be visited. This information is recorded a journal (Form 8LL). This information is telephoned at once to the oper Borough Office of the Bureau of Infectious iseases of the Department of Health. Each institution forwards at intervals a census of s patients (Forms 208 and 257 L), giving name, ite of admission^ and condition at the time of •port. HOME COiNDITIONS OF RIVERSIDE CASES. I : Sec. 184. In order to determine whether patients lould be allowed to visit their homes, every River- 145 side patient, immediately on admission, makes api- cation for a pass to leave the hospital. A special cd is used, which is forwarded from the hospital to Admission Bureau, and thence to the proper Bra Office for investigation and report as to coudition.^ the patient's home. The card is returned through Bureau to the hospital. It does not supersede "home conditions" card. Passes are issued only a report on home conditions. Applicants whose teeth need attention are refer' to the dentist of the Bureau, card (Form 207 L). suits of examination and treatment are entered oa special card (Form 256 L). Placards of information regarding sanatorium i- Quirements are issued to all tuberculosis cliia (Forms 88 and 90 L). SANATORIUM APPLICANTS. Sec. 185. The Admission Bureau is also responses for the admission of all cases to the Sanatorium li the Department of Health at Otisville, New Yc, and to the New York State Hospital for Incipiit Tuberculosis at Ray Brook, New York, and Montefie Country Home at Bedford Hills. Preliminary md- cal examination may be made at any of the tut'- culosis clinics throughout the city. But all applicaa must be referred to the Admission Bureau i economic and final medical examination. OflSd examiners for Ray Brook and Otisville are connect with the Admission Bureau. Patients unsuitable r admission to the above institutions, or who woi have to wait a long time for admission (both in'- tutions having waiting lists) are properly cared * at once and much harmful delay avoided thereby. 146 BUREAU OF INFORMATION. Sec. 186. Full and up-to-date information regard- g all public, semi-private and private institutions r the care of tuberculosis is kept on file at the Imission Bureau. A card of information for physi- ms is issued (Form 101 L). A special information tdex and waiting list is kept for applicants for Otis- lie, Ray Brook, the Preventorium, Seton, and River- le hospitals (Form 203 L), and clinics and physi- ms referring cases are notified as to the result of e various examinations and investigations (Form 4 L). A complete description of the workings of e Bureau is given in the Handbook of Help for )nsumptives (2 L) which is given out at the Bureau. THE TUBERCULOSIS PREVENTORIUM FOR CHILDREN, FARMINGDALE, N. J. jSec. 187. The Preventorium is for children be- ^en the ages of four and fourteen who are predis- sed to tuberculosis, preference being given to those milies in which a case of tuberculosis exists. Applicants must be examined by a physician, pref- ably at one of the tuberculosis clinics, who should I out and sign the medical report blanks, which ly be obtained upon written or personal applica- m to the Hospital Admission Bureau. Blanks must ■ filled out in duplicate and sent to the Bureau. The 'pllcants are then placed on a waiting list from ^lich they are drawn for a final examination by e Medical Examiner for Admission to the Preven- rlum to determine their acceptance or rejection, 147 No child will be admitted who has tuberculosis U an infectious stage. A tuberculin test must be made in every case, ai ; a report of the result entered upon the applicatidij blank. i No children who are known to have been exposi to any of the acute contagious diseases within thr< weeks of the date of their final examination f» the Preventorium are eligible at that time. Tl presence in the house in which the children live, any acute contagious disease at the time of the fini examination, also temporarily disqualifies them. Moreover, the presence of hypertrophied tonsil adenoids, carious teeth, or pediculi or nits in the ha may be a cause of non-acceptance until such cond tions are corrected. In order to save time and lab( for all parties concerned, it is, therefore, requestt that nurses have these conditions remedied befoj bringing the children for examination. Clinic nurses will be notified of the date of tt final examination which will be held at the Hospiti Admission Bureau. Children who are accepted wi go to the Preventorium within two or three wee! of the date of their acceptance. Nurses will be notified five days in advance whei ever possible, of the date of departure for the Pri ventorium. At the appointed hour they must ha\ their charges at the Hospital Admission Bureai From here the children are taken across the ferr by the nurse from the Hospital Admission Burea to meet the Preventorium nurse. Children who d not appear for the final examination when directe 148 lill be placed in the rejected list, unless reason for ich non-appearance is promptly furnished. I Prompt notification to the Hospital Admission [ureau must be made of any children already ac- ipted for the Preventorium who are found unable |.go. Every child on date of departure must be supplied jith a complete outfit of the following articles : I One extra dress or suit of clothes, 1 petticoat for rls, 1 extra pair of strong shoes, 1 pair of over- loes, 3 extra pairs of stockings, 2 extra suits of iderwear, nightdrawers, 1 brush and comb, 1 tooth ush. In winter (September 15- March 15) they require in Idition : One warm coat or sweater, 1 pair woolen mittens, cap covering ears, 1 pair rubber boots. Failure to provide these will prevent the child's ?ceptance. All clothing should be in good condition and packed jatly in a bundle. In addition each child should have a light lunch ifore departure. Children are cared for in the Preventorium for )out thi'ee months. Clinics and parents will be )tified when children are to be returned. They are be met on their return at the Hospital Admission ureau at the time specified in the notification. Discharged cases are followed up by a nurse one onth after leaving, and again six months later. A lecial history card is filled out and the result will I tabulated. 149 TUBERCULOSIS INSTITUTIONS MAINTAINED i BY DEPARTMENT OF HEALTH. RIVERSIDE HOSPITAL. Sec. 188. This institution is for a preliminar: period of observation (cases with bad home condition preferred) of all applicants for admission to Otisvill Sanatorium ; for the care of those patients who ar too far advanced for Sanatorium care; for the detei tion of those who have been removed, by force i necessary, from their homes, and those transferre from other hospitals who insist on returning t unsuitable home surroundings. The sputum mus have contained tubercle bacilli within a month. Th hospital is on North Brother Island, in the East Rivei When a vacancy occurs, admission cards (Form 32 L are issued by the nurses of the Hospital Admissio Bureau. If coup6 or ambulance is necessary, the D( partment Borough Office is requested to remove tt patient. All cases must reach the Reception Hospital ( the Department of Health at the foot of East 16t Street, Manhattan, by 1 P. M., as the boat leaves i that hour. Ambulatory cases may cross to the hospiti from the foot of East 132d Street, The Bronx, whenc a boat leaves every hour between 9 A. M. and .5 P. L Information regarding visiting days and hours given in four languages on a special card (For] 31 L). OTISVILLE SANATORIUM. Sec. 189. For incipient and favorable cases, j Otisville, Orange County, N. Y. All applications ai referred to the Hospital Admission Bureau. Specif 150 ference cards (Form 71 L) with envelopes (Form L), giving a brief history of the case, are mailed duplicate to the Bureau. One is kept on file and e other forwarded to Otisville when the patient Is Imitted. Patients are admitted according to the |[ginal date of application. JA^pplicants must be residents of New York City, rsons suffering with tuberculosis, who are not citi- is of the United States, will not be placed upon I list for admission to Otisville so long as there J enough applicants, who are citizens, to fill vacan- s. Minors, whose fathers are not citizens of the lited States, will not be placed on the list. The lowing, however, are not included: 3l — Unmarried women, residents of the United ites for three years or more, who are self-support- ', or whose parents reside in foreign countries, and o are over twenty-one years of age. i — Widows, residents of the United States for three irs or more. -Minors, born in the United States, or those not ive who are over fifteen years of age and are self- porting. Mscharged cases are followed up and information ained as to their outcome (Form 6,5 L). INSTRUCTIONS FOR APPLICANTS. ec. 190. When vacancies occur, the Admission •eau notifies the patients by card (Form 128 L) furnishes them with a circular (Form 227 L), ng rules and list of articles they must take with ■n. 151 TUBERCULOSIS CAMPS AND FRESH AIR SCHOOLS. Sec. 191. The Department of Health maintains tw Tuberculosis Camps on the disused ferryboats, as fo lo\YS : CAMPS. I 1 THE MIDDLETOWN. A— Located at foot of East 91st Street, Manhatta telephone 2957 Lenox; under the direction of tl Women's Auxiliary of the Department of Heal Tuberculosis Clinics. THE RUTHERFORD. B— Located at foot of Fulton Street, Brooklyn, tel phone 1530 Mtiin ; under the direction of the Tub( culosis Committee of the Brooklyn Bureau of Chariti< the nurse-in-charge being in the employ of that orgaj zation. ROUTINE PROCEDURE. Sec. 192. At these Camps are received suital cases of pulmonary tuberculosis in all stages, referi by card (Form 127 L) from Department and otl tuberculosis clinics. Patients must be of good char ter and disposition, and residents of New York Ci All patients discontinue attendance at tuberculo clinics while at the Camps, but monthly reports to their progress are sent to the clinics. The patie are given a hot dinner in the middle of the day i extra nourishment in the mornings and afternoc Physicians of the Department visit the Camps at i ular intervals, examine the patients, and presci any medication necessary. The system of reco 152 ■ed in the tuberculosis clinics is followed on the imps, including a special temperature card (Form .0 L). They are provided with steamer chairs, raps, books and games, A limited number of men, suffering from tuber- ilosis, but able or compelled by circumstances to mtinue at work, are allowed to sleep at Camp Ruth- 'ford and are given a hot breakfast each morning :cept Sundays and Holidays. But no patient can main at the Camp doth day and night. Such cases ,n be better cared for at a hospital. TUBERCULOSIS CAMP NURSES. Sec. 193. Nurses assigned to the Camps perform e usual duties of hospital nurses, i. e., taking and •cording the temperature and pulse of the patients, jsisting at meal times, giving medicines, etc. All Department employees at the Camp are sub- ct to the general regulations of the Department, the authority of the Supervising Nurse, and to the lecial regulations of the Camp. TUBERCULOSIS CAMP REGULATIONS. Sec. 194. All patients must be referred through le of the twenty-nine tuberculosis clinics in New Drk City. The reference card (Form 127 L), which ves the patient's name, address, clinic number, name clinic and other information, is not given to the itient, but is mailed in duplicate to the Boat Camp, hen a vacancy occurs, a nurse visits the applicant, aves an admission card and instructs applicant how reach Camp. One history is filed and the other 153 forwarded to the Hospital Admission Bureau, afte patient has either entered or declined to enter th Camp. These nurses also follow up and report oj delinquent applicants and patients. Patients are ad mitted in the order of their priority. The clinic c reference is notified by daily report sheet. 2. No patient will be admitted who has not : final diagnosis of pulmonary tuberculosis, based o physical examination, the presence of tubercle bacili in the sputum, or a positive Moro or v. Pirquet ir oculation test. Citizens and children of citizens wi! be given preference. 3. A daily telephone report of the previous twentj four hours is made to the Admission Bureau, of th name and address of all patients admitted and dis charged, and the total number of patients at th Camp. All children of school age who are admitte to or discharged from the Camps are separately v( ported to the Executive Office of the Bureau withi one week by card, the full name, age, addres) diagnosis, etc., together with the number and locatio of the school the child attends, being given. 4. Daily record is made of the amount of foo disbursed (Form 79 L), and the reports (Form 84 Lj forwarded to the Executive Office of the Division c Communicable Diseases. A weekly report of the wor of the Camp (Form 70 L) is also forwarded. 5. Admission to the Camp will be renewed by th Supervising Nurse every two weeks. No patient wi be continued who : (a) has not attended the Camp eight days out c twelve ; 154 (b) has disobeyed the rules of the Camp; (c) has bad habits; (d) is dishonest. When said patient is attending school at the Camp, he Board of Education is to be notified prior to dis- ■harge. G. Patients must report promptly at 9 A. M. and amain until 5 P. M. Those who are late will be idmitted only at the discretion of the Supervising s^urse. Patients will be discharged after a stay of three uonths if unimproved ; if improved, they will be re- ained an additional three months or longer, at the liscretion of the attending physicians. Delinquent applicants and patients are investigated ►y the Camp nurses. The card with the nurse's re- )ort thereon is returned through the Borough Office the Camp. 7. All patients will be required to do light work; exceptions may be made at the discretion of the ittending physicians. 8. Patients who apply to the Camp directly with- iut a card will be referred by the Supervising Nurse the tuberculosis clinic of the district in which the )atient resides, by card (Form 141 L), on which is vritten "Applicant for Tuberculosis Camp." 0. At each visit of the patients to the Camp, the ifternoon temperature, pulse, and respiration are loted on the treatment card. The weight is recorded )nce a week. Re-examination of the chest with entry >n diagram card is made at least once in every two 1^ months. All recommendations must be made on { treatment card in ink. 10. The attending physician attends the Cami three days each week and if prevented from attending he should notify the Supervising Nurse promptly b; telephone. 11. Nurses report promptly at 9 A. M., and remaii until 5 P. M. 12. The nurses assigned to assist the attendinj physicians with examinations, etc., are to see tha the supplies and instruments are in good order. 13. Thermometers after use are wiped with { pledget of cotton saturated with boracic acid, thei placed in 1 to 20 carbolic acid, and before use an washed in 95 per cent, alcohol. 14. All diagnostic instruments are to be wiped after use, with a cloth wet with a solution of 1 t< 100 carbolic acid. 15. At the close of each examining session al histories are to be returned to the oflSce and prop erly filed. All sputum specimens are to be place( in the collection box, and the office left in goo( order. 16. Attending physicians, nurses, hospital helpers orderlies, etc., will wear gowns when on duty. 17. Smoking and the drinking of intoxicatinj liquors during Camp hours are strictly forbidden. 18. Patients no longer in need of treatment ma; be discharged by the attending physician, but cei tificates of improvement, recovery, etc., are to b forwarded to the Executive Office of the Bureau o Infectious Diseases, to be issued from there. 156 TUBERCULOSIS CLINICS. Sec. 195. The first tuberculosis clinic of the De- irtment of Health was opened March, 1904, at 967 xth Avenue (adjoining the headquarters of the De- irtment at Sixth Avenue and 55th Street), in a lilding especially designed for the purpose. Since lat date similar clinics have been opened through- it the city. For their location and hours and dis- icts see directory, Sec. 2). OBJECTS OF ESTABLISHMENT. Sec. 196. The clinics were established with the fol- wing objects in view: (a) The early recognition and accurate diagnosis ; pulmonary tuberculosis. (b) The careful supervision of persons receiving •eatment, including not only their medicinal treat- ent, but also furnishing them circulars of informa- on in various languages, paper sputum bags and iper handkerchiefs. (c) The continued observation at their homes by le district nurses of indigent, needy and ambulatory ises, including all those discharged from public in- itutions of the city. (d) The removal to hospitals or sanatoria of (1) dvanced or bedridden cases with profuse expector- tion, whose presence at home is a menace to others I the family; (2) cases able to get about but who re unable to work, and who are entirely dependent pon their earnings for their livelihood; (3) incipi- 157 ent cases, who stand a fair chance of recovery if r moved to sanatoria outside of the city, and (4) lod ing house, or homeless cases. (e) Provision of municipal institutions to whi< cases of tuberculosis may be referred (1) by phys cians, (2) by institutions on discharge therefrom, {i by the various charitable organizations throughout tl city, and (4) by persons doing individual charitab work. (f) The extension and strengtbening of the sar tary control of tuberculosis among the poor. (g) The care of laryngeal cases. CLINIC STAFF. Sec. 197. The Clinic Staff is organized as follows Physician-in-charge of the Clinic and Branch ofRc Attending Physicians, two being on duty for eac class. Assistant Attending Physicians, available in cas of absence of Attending Physicians. Attending Laryngologists. Volunteer Physicians. A Supervising Nurse and various nurses assigne to duty in the men's clinics, the women's clinics, tii registration rooms, and the throat rooms. Thes nurses also do regular district work, dividing thei time between the clinic and the district. In Manhattan, nurses are detailed to assist and d special work for the Women's Auxiliaries of the Tube) culosis Clinics. 158 PHYSICIAN-IN-CHARGE OF CLINIC. Sec. 198. The Physician-in-charge, in addition to ipervising the work of the clinic under his charge, ibmits each Monday a report (Form 156 L) to the liief of Division, giving the number of patients seen jring the previous week, classifying them as old, new, ale and female, under observation at home, receiv- tg extra diet or referred to hospitals and charitable •ganizations and the number of prescriptions issued, 'taining a copy (Form 112 L). He submits a monthly report to the Association ' Tuberculosis Clinics, the data for said report being itered daily on a loose-leaf record (Form 151 L). He also submits an annual report of the work per- )rmed, makes inventories of stock of blanks at stated itervals, and keeps a diary of current events. OiRGANIZATION. Sec. 199. Each clinic contains a registration room, drug room, waiting rooms, throat department (ex- ?pt in Queens and Richmond), and clinics for male Qd female patients respectively, each with its ex- mination room. Coincidentally with the establishment of the new iuics, the entire system of conducting the clinics as been revised and made uniform throughout all boroughs. According to the number of weekly sessions each linic has been provided with a corresponding num- er of attending physicians, assistant attending phy- icians, nurses, clerks, etc. A uniform system of egistration, described later, is in use in all clinics. 159 FURNITURE, SIGNS, MAi*S, ETC. Sec. 200. The furniture (desks, benches, stool; history cabinets, drug cupboards, etc.) are of meta enameled white. Large wooden signs are hung on the walls of tL waiting rooms, giving the following instructions i English, German, Italian and Yiddish: DO NOT SPIT ON THE FLOOR OR INTO ANT THING EXCEPT THE PAPER IIANDKERCHIB GIVEN YOU FOR THE PURPOSE. WHEN YO^ COUGH, HOLD THE PAPER HANDKERCHIEF BI FORE YOUR MOUTH ; USE IT ALSO FOR WIPIN YOUR MOUTH OR NOSE AFTER SPITTING O: SNEEZING. DO NOT SPIT ON THE FLOOR O; INTO ANYTHING EXCEPT THE PAPER HANI KERCHIEF, WHICH IS THEN TO BE PUT IN TH PAPER BAG AND NOT USED AGAIN. MEN AR FORBIDDEN TO SMOKE OR WEAR THEIR HAT WHILE IN THE CLINIC. « Framed maps showing the districts and locatioi of all tuberculosis clinics in all Boroughs hang o the walls of the registration rooms. Each clinic ha also an enlarged compo-board map of its district, o which are indicated, by means of colored pins (re( children; blue, adults), the current cases in attent ance at the clinic. Each clinic is also furnishe with a large framed chart giving the requirement of the various sanatoria receiving cases from Ne^ York City. Separate lavatories are provided for men and fc women patients. Individual paper drinking cups are furnished th 160 itients for drinking purposes and destroyed after ;e. All floors and metal furniture are cleaned every orning, and the buildings are disinfected with for- aldehyde gas every two weeks. The gowns supplied •e disinfected at the same time, before being sent to le hospital laundry of the Department of Health. AH undry must be plainly marked and accompanied by a invoice. FORWARDING OF REPORTS. Sec. 201. All reports (other than daily reports to ranch Office), time sheets, uotiflcations of absence, ^commendations for exclusion or readmission to :hool, requisitions, inventories, prescriptions, etc., re forwarded through the local Branch Office and lorough Chief to the Executive Office at Depart- lent Headquarters. All blanks, supplies, etc., per- il ining to the work of the tuberculosis clinics are ?sued on requisition, and all requests for infor- mation, histories, records, etc., are handled by the Executive Office. All records of cases transferred to ion-Department clinics are filed in this office. )AILY REPORT TO AND FROM THE BRANCH OFFICE. Sec. 202. Each day the clinic forwards to its ^ranch Office a report (Form 94 L) of all new cases )f tuberculosis seen or diagnosed during the pre- ;eding twenty-four hours ; all cured cases and those, previously reported as tuberculosis, found to be free "rom tuberculosis ; all changes of address and other ..mportant data furnished by the patients themselves ; Imd all cases discharged for non-attendance. A simi- I 161 lar report (Form 89 L) is received daily from tt Branch Office giving all information regarding cas( of tuberculosis living in the clinic district, receive at the Department of Health during the precedir twenty-four hours; new cases reported by sputui examination, postal cards from physicians, cod plaints; all cases reported by the Hospital Admissio Bureau as having entered or been discharged froi hospitals or sanatoria, and applicants for hospit? care; all deaths from tuberculosis; and all cas( transferred from other tuberculosis clinics. Thes cases are looked up in the clinic records and prope entries made. REPORTS TO HEADQUARTERS. Sec. 203. Each clinic reports daily by telephon to the Executive Office the number of new and ol< cases seen the previous day, and absences and return to duty of clinic employees. A weekly report of th: work performed is also forwarded, and a monthly re port to the Association of Tuberculosis Clinics. TABULATION OF STATISTICS. Sec. 204. A current statistical tabulation shee (Form 268 L) is maintained in each clinic on whiel are entered the more important facts regarding ever: case of tuberculosis. To prevent duplicate tabulatioi when cases are transferred to other clinics the wore "tabulated" is stamped on the history envelope. A1 the end of each year these figures are summated. ROUTINE PROCEDURE. Sec. 205. The name, address, age, sex, nationality, employment, history numher and clinic class of every 162 w applicant is entered in a journal (Form 218 L) ; =0 the history number, sex, class and diagnosis of lery patient returning for treatment. The entries on ( ch day for morning, afternoon and night classes have narate headings. The totals for each day are entered I a daily record sheet (Form 73 L). A positive (ignosis of tuberculosis is only recorded after being (Qfirmed by (a) re-examination by another clinic ysician ; (b) the presence of tubercle bacilli in a sputum; (c) re-examination at the Hospital Ad- ; ssion Bureau ; or (d) admission to a tuberculosis spital or sanatorium. Such confirmation is entered : the journal after the diagnosis. "O. K." for re- .amination; "X" for positive sputum. An admission card (Form 7 L), numbered to corre- jiid \Yith the history, with an envelope for the same 'orm 92 L), a sputum jar and a paper handkerchief . d waterproof bag are given to each new patient, zether with instructions as to care of expectoration, 'Ughing, etc. All information on the front of the primary his- [■y card (Form 104 L) is obtained by the registra- )n room nurse, who observes the following instruc- )ns in taking the patient's history. INSTRUCTIONS FOR HISTORY TAKING. Sec. 20G. The clinic case number is to be entered every instance. The date is to be stamped plainly. The number denoting class is to be used, but the ysician's name is to be entered by himself. The name and address of the patient are to be ven in full, plainly and correctly. 163 Ground or stoop floor is "first floor"; one flight ) is "second floor," etc. State "family" if patient lives at home; name I landlord, if boarding. Give name and address of person referring patie to clinic ; use abbreviations if referred by an orga - zation. Give reason for coming — treatment, diagnosis, i mission to hospital, Ray Brook or Otisville. In stating nationality, if Hebrew give country, e. , Russ., Hebr. ; if mixed parentage give both, as Ai Germ. Give occupation followed during period previc? to illness. In obtaining family history, inquire as to cardii or renal disease among relatives and their age death; the same for pulmonary tuberculosis or a pulmonary disease. (If all immediate relatives a; living and well, say so.) Give date of contact with any other case of tub- culosis. Inquire carefully as to colds, sore throat, influen:, pneumonia, pain in chest, and give date and dui- tion. Inquire as to other diseases, operations, etc., w:i particular reference to pulmonary history. Sc£) wounds or cut fingers are not important. Personal habits include excesses in any fori; drugs, or alcohol to excess at any time; do not wrJ "none" if history shows alcohol taken in the pas; the same for tobacco. 164 Inquire as to previous treatmeut In any hospital, ispensary or by a private physician, and nature of Iness ; date and duration ; condition on discharge ; tay in country, date and duration, improved or not ; ain in weight. Present illness, taken generally, means probable ulmonary tuberculosis. Find out the earliest pos- ible symptom, such as loss of weight, loss of trength, loss of appetite, pain, occasional cough, ^nvalescence from other diseases as pneumonia, rphoid, influenza, pleurisy. In inquiring as to initial symptoms remember that ulmonary tuberculosis does not begin with hemor- tiage or night sweats, and seldom with cough. Make nswers cover as nearly as possible the whole period f illness, and not only the day on which patient pplies for treatment. If the patient wishes exami- ation, but says he is not ill, remember that unless e probably had good reason for applying for treat- lent, he would not have done so. Every patient m tell to what cause he attributes his illness. Give the earliest date when pulmonary tuberculosis ecame evident by physician's examination or by efinite symptoms. Describe the various complaints of the patient in le proper spaces : cough, weakness, dyspnoea, pain 1 the chest, loss of flesh, etc. Try to obtain the normal, not the maximum weight. Give date of onset of throat symptoms. State whether appetite is good, bad, failing, im- roving. Indigestion, whether acute or chronic. 165 Constipation, whether recent or hahitual. Diarrhoea, whether occasional, severe, and for ho^ long. Sleep, whether normal or disturbed. State whether fever is recent, for how long, i marked, or slight, and time of day it occurs. Chills, whether slight or severe, and for how lon^ Night sweats, whether copious, severe, occasiona or cold. State degree of weakness, for how long, and i usually in afternoon. Inquire as to severity of cough during day or nighi and spasmodic vomiting after cough. Give number of ounces of expectoration in twentj four hours (estimated), watery, purulent, or hard t raise. State degree of dyspnoea, whether it appears o exertion or is constant, and whether recent or of Ion standing. In questioning as to haemoptysis be sure that epis taxis is not mistaken for haemoptysis; give date o each attack and amount of blood (estimated). Give location of any pain complained of. It is not enough to write down just the answe of the patient. What are needed are facts. N history at all is better than a faulty one. Go ove the questions again and again if necessary. Remen ber that what is important to the physician ofte; appears of no consequence to the patient. Most im portaut are possible sources of infection, contribut Ing illnesses, and the earliest symptoms and date o failing health. 166 I SYSTEM OF FILING HISTORIES. ^ec. 207. All histories, together with the later his- ry card (Form 68 L), throat history (Form 99 L), agram card (Form 211 L), and clinical record •iputum, blood, urine-, X-ray) (Form 212 L), are ed according to year and number in a special en- 'lope (Form 77 L). These cards are all of uniform /e (8 inches by 5 inches), and are of different colors as to be readily distinguished. The following system of filing is used: (a) Current cases under observation. These are pt in the registration room, filed in four groups a week each — i. e., those who have called three ?eks, two weeks and one week previously, and dur- ? the current week. The cases are shifted to the ■rrent week as they visit the clinic. In each group e histories are filed according to year and serial : mber. (b) All records of discontinued cases (non-tuber- od or drinks. EXAMINATION OF APPLICANTS FOR PEDDLER'S LICENSES. Sec. 211. Applicants at the Bureau of Licenses for ermission to peddle, keep stands, or serve as public orters, fall into the following groups : — (a) To peddle (with horse and wagon, push cart or asket). (b) To maintain stands for the sale of newspapers, 'uit and soda water, within the stoop line of build- igs. (c) To maintain newsstands under the stairs of evated and railway stations and behind subway iosks. (d) To maintain stands for hack driving and ex- cess work. (e) To act as public porters, They are referred for examination to the nearest iiljerculosis Clinic. The result of the examination is irtified to (non-department clinics Form 87 L; Depart- lent Clinics Form 119 L), and where the applicant found to have bacilliferous sputum the recommenda- on is made that the application for license be de- led. RECOMMENDATIONS FOR HOSPITAL CARE. Sec. 212. Recommendations by the attending physi- ans for the admission of cases to hospitals are re- trred to the Tuberculosis Hospital Admission Bureau irough the local Branch Office, by means of a special ird (Form 174 L) forwarded in duplicate. 169 Cases for Otisville, Ray Brook and other sanatori are also referred in duplicate on special history care (Form 71 L) which are mailed direct from the Branc Office to the Tuberculosis Hospital Admission Bureai SPUTUM AND URINE SPECIMENS. Sec. 213. Sputum and urine specimens are place by the patients in the covered box provided for thi purpose, and at the close of the day are forwarde to the Diagnosis Laboratory, duplicate slips, nun bered to correspond with the patient's history nun ber, accompanying each [sputum, Form 261 L ; uriu Form 96 L]. All results of examinations are entere on the clinical record card, which is filed with patient history, and also in a sputum journal, according 1 case number. For a description of the method ( examination of sputum at the Diagnosis Laboratoi of the Department of Health, see (Monograph No. 1 on "Registration and Sanitary Supervision of Pu monary Tuberculosis." REPORTING OF NEW CASES. Sec. 214. All new cases of tuberculosis in whic the diagnosis has been confirmed by re-examinatio by a second physician, or by tubercle bacilli beic found in the sputum, are reported the followin morning to the local Branch Office on the specii blank "Daily Report to Borough Office" (Form 94 L used for this purpose. The daily report of new casei deaths, admissions to hospitals, changes of addresi discharges, etc., from the Borough Office is in tur submitted daily to the clinic for correction of 11, records. Doubtful cases, later proving tuberculoui 170 ire similarly reported. All reports and recommendd- ious are forwarded from the registration room by be Supervising Nurse to the Physician-in-charge. DEATHS. Sec. 215. All deaths from tuberculosis, as reported ally from the Branch Office, are looked up in the liuic records; such histories are filed separately, and orwarded to the Borough Office. PROCEDURE IN EXAMINATION ROOMS. Sec. 21G. In the examination rooms the patients t their first visit are weighed, the body tempera- ure, pulse and general condition noted on the his- jry card ; a complete physical examination is made, 11(1 the results noted on history card, and also on iagram card. On the later visit card a "record is lade of treatment ordered or of recommendations jY X-ray examination, extra diet (milk and eggs, L'om the Auxiliary in Manhattan and the Brooklyn lureau of Charities in Brooklyn), and admission to hospital. SYSTEM OF ABBREVIATIONS. Sec. 217. The following system of abbreviations ; used by the attending physicians to indicate the ^^lllt of the physical examination. Only the extent of lesion is shown on diagram card. INSPECTION : xjuansion Exp. Diminished Exp. Absent Exp. O. 171 PALPATION : Vocal Fremitus V. P. Increased V. F. - Diminished V. F. - Absent V. F. < PERCUSSION: Impaired .....,, ,i , . . . ? . . //// Dull - ^_ AUSCULTATION : Respiration B. Harsh R. • Diminished R. - Absent R. ( Broncho Vesicular R.Br. Expiration E. Prolonged E High Pitched E Vocal Resonance V. R. Increased V. R. Diminished V. R. - Absent V. R. ( Bronchophony Bronchop lialos: Fine Medium - Coarse Friction Sounds 172 CONFIRMATORY RE-EXAMINATIONS. Sec. 218. Cases thought to be tuberculous on first r later examination are at once referred to the other linic physician on duty that day for confirmatory xamination. If the diagnosis is confirmed, the sec- nd physician writes "O. K." and his initials after he original diagnosis on the history card. The first xaminer must also enter the stage of the disease, ising the classification adopted by the National As- ociation for the Study and Prevention of Tubercu- osis. Where the two physicians do not agree, the ■ase is referred to the Physician-in-charge for final lecision. All undiagnosed cases which have attended he clinic for a month or longer are also automati- ■ally referred to him for final diagnosis and disposal. INSTRUCTION OF PATIENTS— CIRCULAR. Sec. 219. The patient receives thorough instruc- ion from the attending physician as to diet, mode )f living and exercise, special effort being made, vhere hospital care is indicated, to induce the )atient to enter an institution. In addition a circu- ar of instruction, "Advice for Patients," printed in English - German (Form 139 L) , English - Hebrew fForm 147 L), and English-Italian (Form 155 L) is supplied. MEDICINES. Sec. 220. Medicines are ordered on prescription (Form 74 L) from the clinic formulary (Form 258 L) iu(\ are supplied from the drug room, patients being instructed to wash empty bottles before returning ^ame. Special prescriptions for medicines not in the formulary, after approval by the Physician-in-charge, 173 are obtained from the Drug Laboratory, through tt office of the Chief of Division. A daily record is kej of the number and kind of medicines issued, and ( medicines and supplies received, on a monthly loost leaf sheet (Form 132 L). The weekly requisition for drugs (Form 3Y) mm reach the Executive Office by Wednesday mornini The monthly statement of drugs on hand (Fori 154 L), together with all prescriptions for the pr( ceding month, must be forwarded by the fourth of eae month. THROAT EXAMINATIONS. Sec. 221. r^very new applicant is referred to th throat room for examination and treatment. A sp( cial history card (Form 99 L) is used, on whie treatment and later visits are recorded. Laryngolc gists dispense and are responsible for any cocain issued, sending a voucher to the drug room eac. time. HOME VISITS BY NURSES. Sec. 222. Every case of tuberculosis attending th clinic is visited at suitable intervals by the distric nurse. Her report of the home conditions (Foru 44 Ij) when forwarded from the Branch Office is sub mitted to the attending physician for his informa tion and signed by him, any special informatioi being added to the patient's history card for the in formation of the physician. The nurse repeats hei visits at least once every two months, and mucl oftener if necessary. Pulse, temperature and respir ation are taken at every visit. Reports of later visiti are given on the daily report of the Branch Offic( to the Borough Office, which is submitted to the clini< 174 ach day, wbere reports are entered. Suggestions as diet and general treatment are given by the physi- ian to the nurse. DELINQUENT CASES. Sec. 223. When patients fail to return to the clinic u the date set, a double return postal [English (Form 17 L) ; Italian (Form 276 L)] is sent them one week ater, asking for reason of absence and date of return. Bach day a "delinquent case card" (Form 150 L) s filled out for every patient who has failed to re- urn to or notify the clinic for a period of three veeks. This is forwarded at once to the Branch )flice for investigation by the district nurse, who re- torts why patient failed to attend clinic, whether he v'ill return, and w^hen. Patients are not discharged or non-attendance until a delinquent card has been eturned. STUDY OF CASES. Sec. 224. In connection with the examination and reatment of the patients, the following points are 'bserved : Each new patient is carefully studied, and t first and subsequent visits an earnest effort is iiade by the physician to gain that confidence and exercise that moral control of his patient necessary or attaining good results. To this end, if it seems 'Ivisable, the patient is frankly told the nature of li(; disease, the result of the sputum examination, lis weight, and the general prognosis. This informa- Joii is, however, given only to patients or to those ocorapanying them. 'J'he great importance of proper and sufficient food, r(;sh air and hygienic living is emphasized. 175 FINAL DIAGNOSIS, LATER EXAMINATIONS. Sec. 225. A final diagnosis is made in every cas as soon as possible and is entered in the journa At each subsequent visit of the patient, the bod temperature, weight, pulse, medication and gener£ condition are noted on the later history card (Fori 68 L). The date of the next visit to be paid is als entered on the card, and a nurse personally uotifie each patient. A complete re-examination of the ches with entry on diagram card, is made at least one every month. Patients are advised to return as fr( quently as the physician considers necessary, the ir terval between visits being not longer than one wee! All patients remaining under treatment revisit tb clinic on certain days and hours of each week, accorc ing to the special sub-district of the clinic district i which they reside. On that day and hour of each wee the district nurse of that sub-district is on duty in th clinic; she thus gets in close touch with the patiem promoting the work of the clinic, and giving valuabl information to the attending physician. When re quired to return for a special purpose (tuberculin tes radiograph, etc.), patients are given a special car (Form 5L). Medical reports to the Executive Offic on the physical condition of patients are also made o a special card (Form 87 L). No patient is refuse examination and such medication as is necessary those having no tuberculous lesion are referred t general hospitals and dispensaries. If for any reaso: the physician considers that a tuberculosis patien should not receive further treatment, the matter i referred to the Physician-ln-charge, with a brie statement of facts in the case. No patient with cougl and expectoration is discharged as free from tubercu 176 )s!s unless three negative sputum reports have been ?ceived, and the physical signs and general history -arrant such action. CHARITABLE AID. Sec. 226. Deserving patients who are in need are [ecommended for financial assistance by the attend- »g physicians, and such recommendations are for- i^arded to the Branch Office and there submitted to he local Clinic Relief Committee, if one exists. If ,ot, they are forwarded to the Charity Organization lociety. Association for Improving the Condition of he Poor, United Hebrew Charities, Brooklyn Bureau )f Charities, etc. CLINIC RELIEF COMMITTEES. Sec. 227. At each clinic of the Department of lealth, all recommendations for charitable aid are ■eferred to and acted upon by the local Clinic Relief "ommittee, meeting once a week, and composed of the F'hysician-in-charge (chairman) and representatives )f the Clinic Auxiliary, and of each of the three arge private charitable organizations. (There is one committee for both Bronx Clinics and none for the Queens and Richmond Clinics.) HOME VISITS BY CLINIC PHYSICIANS. Sec. 228. Patients too feeble to attend the clinic are visited by a clinic physician, and medical care provided pending admission to a hospital. Undiag- nosed cases refusing to return to the clinic and new suspected cases of tuberculosis are also visited by clinic physicians for diagnosis, all reports being sub- mitted on a clinic diagram card (Form 211 L). They 177 may also be called on to examine other members o a consumptive family. Cases are assigned by th Physician-in-cliarge, and a record kept in the clini journal. MILK AND EGGS. Sec. 229. The Woman's Auxiliary of the Manhat tan Tuberculosis Clinics of the Department of Healtl and the Brooklyn Bureau of Charities distribute on quart of milk and two eggs daily to each patient a long as required, and groceries and clothing in deseri/ ing cases. RULES FOR ATTENDING PHYSICIANS. Sec. 230. The attending physicians arrive punct ually at 10 A. M., 2 P. M. and 8 P. M., and mus enter the time of their arrival and departure on th< regulation time sheets kept in the registration room They will remain until all patients, both men am women, have received attention. When work is ligh they may be assigned to visit undiagnosed cases. I: for any reason a physician is prevented from attend ing his class, he must notify the clinic promptly bj telephone. Clinic physicians and laryngologists are required to devote four sessions of two hours each to the work of the Department of Health each week. Eacb' physician can, therefore, devote at least two hours weekly to home visiting, in addition to his three clinic sessions, and is expected to make at least two home visits a week. Should more than two hours a week be required for such visiting, the surplus time may be' deducted from the clinic work. Every visit made is to be entered on the back of the time sheet, the total time required being noted. 178 In every case of tuberculosis, institution care is 'commended on the history, or the reason given for 3t doing so. No tuberculous patients are discharged except by leir own request. Previous to discharge, patients )nsidered to be cured are examined and their dis- large approved by the Physician-in-charge. Prescriptions show the date, patient's clinic num- >r, and the physician's signature. A new prescrip- on must be written for each renewal. Each pre- ■ription is recorded on the history card in every ;stance. Prescriptions left at patients' homes are » be written on the official blank or on plain paper, ■"ver on the physician's private prescription blank. If the physician desires that the patient should be ivisited by the nurse, enter a hospital, receive chari- ble aid, be discharged from treatment or trans- rred to other classes, he states this fact on the story card. The system of signs and abbreviations adopted by le Department of Health is used in all cases to indi- ite on the history diagram the result of the exami- ition of the chest. All patients are told to attend the classes at which le district nurse of their sub-district is regularly i "esent. Patients applying for emergency treatment, bwever, are examined and treated by the physician whom they may be temporarily assigned. Medicines are supplied only to tona -fide patients the clinic. Prescriptions are not, as a rule, re- iwed except for patients personally attending the iriic or on presentation of their admission card, 179 by another, but exceptions are made for good reasoi and at the discretion of the attending physician. Whe the clinic formulary is not used, prescriptions must I approved by the Physician-in-charge. VOLUNTEER ATTENDING PHYSICIANS. PROBATIONARY PERIOD. Sec. 231. Volunteer Attending Physicians to th Tuberculosis Clinics are appointed first for a probi tionary period of three months, during which perio they are required to comply with all the regulatior applying to salaried employees as to hours on dut per week ; to submit time sheets every ten days an to forward notifications of absence and requests fc leave of absence. Efficiency records of their servic( are kept, on which and on their length of service ai based recommendations for their permanent appoin ment. APPOINTMENT AND PROMOTION OF VOLUI TEER ATTENDING PHYSICIANS. Sec. 232. The appointment and promotion of Volui teer Assistant Attending Physician to the Tuberculosi Clinics has been made uniform with other appoin ments and promotions in the Department of Health i. e., applicants for appointment, when approved b the Chief of the Tuberculosis Division and the Dire tor of the Bureau of Infectious Diseases, are appointe by the Board of Health, Recommendations for the: appointment to fill vacancies in the salaried staff ai based on their efficiency records and on their lengt of service. Such vacancies are also advertised in tt publications of the Department. 180 CLINIC NURSES. Sec. 233. All nurses assist in preparing clinic sup- ies when not otherwise engaged, and all maintain ueral supervision over the patients, seeing that they e supplied with sputum pouches, and use them, that ey hold paper napkins before the mouth when cough-* g, that drinking cups are only used once and then rown into the receptacle provided, etc. RULES FOR CLINIC NURSES. Sec. 234. The white gowns furnished by the De- irtment are worn while on duty. Nurses devote as uch as is necessary of the first hour of each clinic ly {i. e., from 9 to 10 A. M., or 1 to 2 P. M.) to eir work in the Branch Office, obtaining assign- ents, etc. At the night classes, nurses on duty re- »rt at 7.30 P. M. One hour is allowed for lunch, but at least one irse must always be in the registration room. Each nurse sees that the supplies and instruments the room under her charge are in good order. Thermometers after use are wiped with a pledget cotton saturated with boracic acid, then placed a 1 to 20 carbolic acid solution. Before use they •e washed in 95 per cent, alcohol. All diagnostic instruments are wiped at the close ' each day's session with a cloth wet with a solu- Dn of 1 to 100 carbolic acid. During the noon hour all the windows and inside )ors are opened for the airing and ventilation of the •oms. At the close of each class, all histories are returned the registration room. 181 CIRCULAR OF INFORMATION. Sec. 235. A "Circular of Information Regardli the Clinics for the Treatment of Pulmonary Disease (Form 60 L) is issued by the Department and di tributed to physicians and those interested. THE WOMEN'S AUXILIARY TO THE TUBERC LOSIS CLINICS OF THE DEPARTMENT OF HEALTH. Sec. 236. This association is made up of ladi interested in the work of the Manhattan Tuberculof Clinics. Separate committees have been organiz for each of the clinics, together with a central coi mittee. The work of the Auxiliary includes: 1. The direction of the Tuberculosis Camp Midd town. This includes everything connected with t Camp, except medical care and supervision of t patients. 2. Furnishing charitable aid in worthy cases i ported by the Manhattan Tuberculosis Clinics of t Department of Health; this takes the form of gi ceries, clothing, fuel, assistance with rent, etc. Nurs with a knowledge of social service are detailed assist the Auxiliary at each clinic. 3. Furnishing outfits to indigent applicants i| Otisville Sanatorium, and the Preventorium. 4. Supplying milk and eggs as extra diet, in su' able cases from the clinic, also modified milk fro the Babies' Dairy, to the babies of clinic patients. 5. Co-operation with the local Clinic Relief Co- mittees. 6. Maintaining and conducting the Chelsea D' Nursery at 346 West 27th Street, for the children ' tuberculous parents. 182 rHE ASSOCIATION OF TUBERCULOSIS CLINICS. Sec. 237. The Tuberculosis Clinics of the Depart- nent are members of the Association of Tuberculosis Clinics. This Association is composed of the tuber- lulosis clinics which divide the various Boroughs of ^ew York City into districts, all applicants being re- ferred to the clinic of the district in which the appli- ■ant lives; patients refusing to attend those clinics re visited by nurses of the Department of Health, md if in need of treatment are notified that they must ttend the clinic, put themselves under the care of a irivate physician, or else enter a hospital or sana- orium. The children of those patients found to be uberculous are also examined in these clinics. In Jrooklyn, The Bronx, Queens and Richmond the only uberculosis clinics are those maintained by the De- artment of Health. The Department issues a circular of information re- arding the Association of Tuberculosis Clinics (Form L) ; also reference cards used for transferring cases Form 141 L) and folders for use by charitable or- anizations for referring cases to the clinics (Form 8L). Every clinic submits a monthly report to the Asso- iation. For complete list of names, addresses and ours of clinics, see Directory Sec. 2. DIVISION OF TYPHOID FEVER. Sec. 238. The Division of Typhoid Fever is charged ith the registration and sanitary supervision of all ises of typhoid fever occurring in New York City. 183 CHIEF OF DIVISION. Sec. 239. The Chief of Division exercises genera supervision over all matters pertaining to the work o: his Division throughout the City. OFFICE OF CHIEF OF DIVISION. Sec. 240. In the office of the Chief of Division th. accuracy of statistical figures is supervised and tht results of the various activities in the Borough am Branch Offices are carefully tabulated for the purposi of bringing out the essential factors in the causatioj and control of infection. TYPHOID CHARTS AND TABULATIONS. Sec. 241. A chart is kept showing the number o cases reported daily and weekly from each Borougl and from each ward therein, the corresponding figure for the year previous, and the averages for five year by wards and boroughs. MAPPING OF CASES. Sec. 242. Each case reported is at once plotted o a large compo-board map of the Borough by colore tacks indicating the possible sources of infectioi as follows : Red — Out of city during the incubation period. Yellow — History of exposure to typhoid fever. Blue — ^All other sources of infection. Two such maps are kept for each Borough, on showing all cases for the calendar year and the otht current cases only. A map showing business addres of each case is also kept. 184 I There are also kept: (a) a tabulation for each Borough showing the most important features related :n the histories. (b) A chart for each Borough showing the num- ber of cases using milk from the various wholesale railk dealers. This is so arranged as to show the age, mset and locality (district) for each case. (c) A chart showing the number of cases using milk 'rom the various country creameries. Any localized or general increased prevalence is thus speedily brought into prominence, its cause is sought "or, and reports and recommendations regarding any leedful action by the co-ordinate branches of the De- )artment, or if necessary by other City Departments ire made to the Director. A daybook is kept containing the name and address j)f each case reported, the date of assignment to the Inspector and the date the history is received in tbe )ffice of the Division of Typhoid Fever. A record is kept in a "suspected case" book of cases >f typhoid fever in which there is a positive diazo 'eaction in the urine only, and of those in which he Widal test is negative, but a positive clinical diag- losis has been made by the attending physician. If .he diagnosis is not confirmed by a postal from the )hysician or positive blood specimen, within one week )f the receipt of the original laboratory specimen, the ittending physician is communicated with by telephone o obtain his opinion as to the disposal of the case as rue or false. A journal is kept of all immunizations against yphoid fever together with the number exposed and mmunized for each case. 185 The typhoid fever histories are forwarded after the first inspection, directly to the office of the Division of Typhoid Fever by the Branch Office. Six weeks later the final history of the case is obtained by let- ter, the physician or hospital being requested to fur- nish information on a special blank (Form 67 L) as to subsequent course and outcome of the case. Should no reply be received within one week, the case is re- assigned to an inspector, who visits the attending physician or the hospital (with the consent of the attending physician) and ascertains whether there was: (1) recovery or death; (2) relapse; (3) perfora- tion; (4) hemorrhage; (5) whether sequelae devel- oped, and (6) the duration of the illness in week- periods based on the date of onset, and date tempera- ture reached normal. A letter (Form 181 L) is sent to all physicians reporting cases more than two weeks after the onset of the disease, requesting an explana- tion of the delay. When all the above data regarding a terminated case are received they are duly enterec on the history card, which is then sent to the Borougl Office for the terminated case file. The office of the Division of Typhoid Fever makes the following reports: (a) A weekly report showing the average daily time of inspectors in the field, anc the number of visits and immunizations performed (Form 171 L) ; (b) a weekly report in duplicate show ing the number of typhoid fever cases in each Bor ough and in the City, as compared with corresponding periods for the previous year and the average for fiv( years; (c) a weekly report in triplicate showing th< cases in each Borough by districts (Form 183 L) ; (d^ a monthly report showing the average daily time fo] each inspector; and (e) annual and semi-annual re 186 )rts analyzing and summarizing the work performed, ith a brief but adequate discussion of all matters of ►ecial Interest. rPHOlD FEVER NOTIFICATION AND REGIS- TRATION. Sec. 243. Notification : The procedure for notifica- on has already been described (Sees. 38, 39). REGISTRATION. BOROUGH OFFICE. All cases are reported to the respective Borough ffices, there compared with the current envelope case es of infectious diseases and then telephoned daily ; 8.30 A. M. to the proper Branch Offices, where they •e assigned to the inspectors, and nurses for inspec- on and sanitary supervision. The original postal id laboratory reports (Forms 7 J, 126 L, 11 L) are led in envelopes (Form — L) in the current case le and the case is entered in the house file. When e cases are terminated, and the histories are returned •om the Office of the Division of Typhoid Fever they re placed in the envelopes containing the original sports and refiled in the terminated case file, thus )mpleting the record for each case. Each Borough Office submits and records the fol- wing reports: (a) Daily telephone report to the entral Executive Office by 9.15 A. M. ; (b) weekly immary of the number of cases of typhoid fever; c) daily report of name, age and address of all new isGs (dead and living) of typhoid fever reported to le Manhattan Borough Office for printed school list; d) monthly report showing correct number of cases 187 and deaths of typhoid fever, to the Executive OfBc [Note. — The monthly records are held open until tt 8th of the following month to allow for the dedu< tion for "no cases," all of which are deducted froi the figures of the month in which they were original! reported. All "no case" reports received after tb expiration of the month are reported as of the las day of the expired month.] A duplicate report car is made out and forwarded daily to the Typhoid Divif ion for each case of typhoid fever reported, whethe by postal, positive blood specimen, telephone complaii or otherwise. All reports of cases are acknowledged by postal. BRANCH OFFICES. Sec. 244. These offices receive their new cases dail at 8.30 A. M. and assign them to the medical inspec tor, who calls each morning. His daily report (se Sec. 246), when completed, is forwarded direct to th Office of Division of Typhoid Fever. The typhoid in spector reports, and is directly responsible to the Chiel Division of Typhoid Fever. A history card (Form 184 L) is made out for eacl case. On completion of the investigation, it is re turned to the Branch Office, where it is scrutinize( for:— (a) Non-observance of precautions. Such cases ari then visited by a nurse to see whether precautioni as outlined on hanging card have been instituted sine the inspector's visit. If these measures are in force she will revisit weekly to insure their continuance, precautions have not been instituted, she will repea the instructions and revisit at an early date. Con tinned negligence will then be reported by telephon 188 3 the Typhoid Office by the Physician-in-charge of the iranch Office followed by a written report (Form 3 L). Revisits are assigned by means of the Branch Office illy file, a subsequent history card (Form 267 L) eing made out by the nurse and forwarded to the ffiee of the Division of Typhoid Fever on termina- ion of the case. (b) For cases using milk purchased from stores; ach cases are immediately telephoned to the Officer- i-charge of the Sanitary Squad of Police in the Bor- ugh for investigation, giving name and address, date f onset and name and address of milk stores. The history cards (Form 184 L) should be for- '^arded daily to the office of the Division of Typhoid 'ever. INVESTIGATION OF MILK STORES. Sec. 245. These are investigated by sanitary patrol- |ien who report on milk history card (Form 252 L), le condition of the stores and the source of the milk apply in the city and in the country as shown by ae milk tags kept on file in each store. These re- orts Ire forwarded direct to the Office of the Division f TyiDhoid Fever.* Any unsanitary condition or violation of regula- ions is included in the report which is made out in uplicate, and promptly forwarded to the Division ►ffice. One copy is immediately delivered to the lureau of Food Inspection. INVESTIGATION OF CASES BY TYPHOID INSPECTOR. Sec. 246. The inspector visits the homes of patients, icluding those in hospitals (with the consent of the 189 attending physician), and obtains all required informs tion. He investigates the milk supply, states specil cally whether the milk was bottled or loose, whethi purchased from a wagon or store and gives the nan and address of the dealer. (Whenever the inspect( finds two or more cases that have purchased mil from the same store, he immediately notifies the ofla< of the Division of Typhoid Fever by telephone.) 1 distributes hanging card of instruction (Forms 178 136 L, or 198 L.) Whenever proper precautions are not being observe the inspector makes a special report (Form 3L) gi ing particulars and making recommendations. If tl necessary precautions cannot be observed, or are wi fully disregarded, the case may be removed to ho pital, in accordance with the Sanitary Code (s( Sec. 4 H). If the patient is ill at home, the inspe tor makes certain that all precautions against tl spread of the disease are being observed, gives verb; instructions where necessary, and in any event leav a copy of the hanging instruction card, printed English, Italian, German and Yiddish, entitled "Ho to Avoid the Contraction and to Prevent the Spres of Typhoid Fever." (Forms 178 L, 136 L or 198 L Whenever two or more cases are reported in tl same family or home, the inspector makes a simili report, showing the connection, if any, between tl cases. Inspector's complaints as to unsanitary cond tions are forwarded to the Division of Inspectioi for further action. If flies are numerous on the prei ises, the existence of a stable in the immediate vici ity is sought for. If found, inspection of the stab for possible violations of the provisions of the Sar 190 •y Code dealing with the disposal of manure is commended, and verbal and written instructions orm 53 A) given regarding the danger of the spread ( the disease by flies. The histories are returned the inspector to the Branch Office the following )rning. ANTI-TYPHOID IMMUNIZATION. Sec. 247. The typhoid inspectors, upon request and th the approval of the attending physician, perform ti-typhoid immunization. Applicants for immuniza- in having no attending physician may have it done the Headquarters of the Department and at general ipensaries. The culture is furnished free to physi- mg and dispensaries. Requests are received by tele- one or letter. The culture used is a suspension of phoid bacilli of weakened virulence, killed by heat. iree inoculations at intervals of from seven to ten ys are given, the first dose being 500,000,000 killed cilli and the two later doses 1,000,000,000 killed ^cilli. For persons employed in business, successive Uturdays are convenient times. The inoculations are ven with a hypodermic syringe, the injections being a fie at about the insertion of the deltoid muscle. If e injection is given at 4 P. M., the reaction, any, will occur at bedtime. Careful antiseptic pre- utions must be observed. The probability of the currence of a reaction and its nature should be plained to the patient. The injection causes some lii), which quickly subsides. After a few hours a d, tender oedematous area, several inches in diam- (tv, develops at the site of injection. There may also ; headache, malaise and fever. But neither the local 191 nor general reaction should cause alarm. There is relation between the fever and reaction, and t amount of immunity conferred. Anti-typhoid immu zation should only be performed in healthy subjeci, who have previously undergone a thorough physi(* examination. No person having or suspected of having tuberculoi in any form, should be immunized. The inspectors offer immunization to all membe| of every family in which a case of typhoid fever (f curs, subject to the approval of the attending phyij, clan. ' Placards (Form 262 L) recommending anti-typhoi: immunization are distributed to dispensaries for t\i information of the public. i The Research Laboratory supplies the necessaif, three doses of culture either in individual vials, or 1^ 10 c.c. vials. The inspector forwards a report of ea([i case immunized (Form 245 L) immediately after tlj: third inoculation. A circular of information (Fori 250 L) is issued and distributed. [ A circular of condensed information, printed in foiif languages, for "the man in the street," is also diij tributed (Form 281 L.) \\ SPECIAL INSTRUCTIONS FOR TYPHOID INSPECTORS. Sec. 248. The day the patient went to bed Is li| be considered as date of onset. In very mild or ambil latory cases, the inspector will use his judgmenl The date physician was called must be given and al6 date prodromal symptoms were first noticed. In flmj 192 spections, the date temperature reached normal must given. If the disease was not contracted on the premises, e previous address is to be given. Full details, including dates of onset, are to be ren of other cases in family or elsewhere, where I ere is likelihood of infection by contact. Any one who regularly takes raw milk as a bever- ;e, if only one or two glasses a week, is to be con- iered as an "Habitual milk drinker," but the source milk supply is to be given in every case regardless habits of patient. Inclusive dates when patient was out of town are to given. If patient was away for only a day or part a day, that fact is to be plainly stated. Special care must be taken in obtaining data as to ciipation. A general term such as clerk must not • accepted. DISINFECTION. Section 249. For regulations governing disinfection cases of typhoid fever, see Sec. 96. QUARANTINE. ' Sec. 250. The regulations governing quarantine cases of typhoid fever in the rear of stores, among 'Od handlers and in the family of a janitor or ijieilntendent are the same as obtain in other infec- iiis diseases. No convalescent, whose business has (V) with food products, may return to work, until ..iiiiination of stools and urine show typhoid bacilli ■ 1)0 no longer present. 193 DIVISION OF NURSING. SUPERINTENDENT OF NURSES. Sec. 2.51. The Superintendent of Nurses has chai of all nurses in the Bureau of Infectious Diseas She is responsible for their punctuality and atte: ance, reporting all absences and returns to du making all assignments and details. She submits 1 following report: — Each Monday a weekly report to the Execut Office of the work of the district nurses for the prec< ing week (Form 142 L). A daily telephone report to the Executive Office all absences from and returns to duty. A monthly report of the total number of hours duty of each nurse. She maintains a loose-leaf weekly record of i work of every district nurse (Form 98 L). She also submits an annual report of the wo under her charge to the Chief of Division, tak inventories of her stock of blanks at stated Interva and keeps a diary of current events. She holds a weekly conference with the Supervisii Nurses at which all new procedures are discuss© new orders transmitted, etc. SUPERVISING NURSES. Sec. 252. In each district of each Borough oi nurse is detailed as Supervising Nurse. She is und the immediate direction of the Physician-in-chari of the district, and is also responsible to the Superi tendent of Nurses. She has general supervision i the work of all nurses detailed to the district ax 194 ;linic. She submits a daily report (Form 259 L) to he Superintendent of Nurses. Her duties are to trans- nit orders ; to make visits with and instruct new and ess competent district nurses ; to investigate daily *-eports of district nurses and voluntary renovations ■•eported by them ; to visit cases under observation, and f-eport as to condition; to hold weekly conferences Vith her nurses, and discuss various topics connected vith the work; to supply nurses with cards, blanks, !;tc. * REGISTRATION AND CLINIC NURSES. Sec. 253. Registration nurses in Branch Offices are •esponsible to the Supervising Nurses for the accuracy md completeness of all reports and files located in ':heir district unit. The nurse in charge of the Clinic is responsible to he Supervising Nurse for the accuracy and complete- ness of the records and files of all cases of pulmonary 'uberculosis cared for by the clinic. j DISTRICT NURSES. I Sec. 254. The duties of the district nurses are di- |7ided into home visiting in cases of tuberculosis, scar- et fever, measles, diphtheria, cerebro-spinal menin- ritis, acute poliomyelitis, whooping cough, typhoid ifever, and also tuberculosis clinic work. In the clinics fhe nurses receive patients and prepare them for phy- sical examination by the physician ; take temperature, |iulse, respiration, weight and height, supply patient kvith literature in their own language and instruct jthem in the necessary sanitary precautions which they Should observe. 105 The district work consists in the sanitary supe vision of patients suffering from infectious diseas( and in the instruction of the patients and their fani lies in methods of prevention of disease, and of efficiei isolation, disinfection, etc. Plans for social bette ment frequently originate from these home visits. DISTRICT NURSES' OUTFIT. Sec. 255. When on duty in her district every nurs carries with her : Clinical thermometer. Watch with second hand. Fountain pen. History cards (Forms 44 L; 184 L and 20 J). Cards for referring patients to clinic (Form 141 L Circulars and hanging cards for information r garding infectious and contagious diseases (see Sec 4 A, 4 B and 4 C for list). Sputum bags and paper napliins. Blue clinic information cards (Form 149 L). Sputum bottles. Notification postal cards (Form 5 J). School exclusion and re-admission cards (Forn 14 J and 7 J). School exclusion report to Bureau of Child Hygien (Form 151J). Placards (Forms 113 L ; 44 J ; 47 J and 120 J) . Fumigation cards (Forms 232 L and 94 J). Pland Book of Bureau (Form 202 L). Each nurse should also have a supply of : — Daily report cards (Form 259 L) or time record (Form 23 A). 196 Renovation orders (Form 48 L). Notification of absence blanks (Form 210). Reserve stock of various cards and printed forma 5ed. All above supplies to be obtained from ber Super- sing Nurse. GENERAL DUTIES OF DISTRICT NURSES. Sec. 25G. All district nurses should thoroughly fa- iliarize themselves vrith all sections of the Hand- lok of Bureau of Infectious Diseases (Form 202 L), tiich pertain to their work. They should also be miliar with the system of registration employed the Branch Offices and Clinics. Every district nurse is expected to be on duty at ist six hours daily, exclusive of one hour for lunch- in (Saturdays, three hours daily). The Depart- ijnt badge is to be worn when on duty. Nurses must wear suitable clothing. NURSES' DAILY REPORT. Sec. 257. Every nurse not on exclusive clinic or (jice duty in the Branch Ofiice, submits a daily report I her work for the preceding twenty-four hours 'orm 259 L). This report gives date, name and •strict of nurse, total number of new visits, revisits, *3 name and address of each patient visited and the lur when nurse reached the premises. On the re- Tse of the card is given a summary of the day's ^>rk, and the total number of hours on duty sub- (/ided into (1) on district, (2) at clinic, and (3) ' Branch Office. It is made out in advance each inning, every assignment and its nature being en- 197 ! tered thereon, aud is left at the Branch Office. Tl next morning the hour of arrival at each address entered. The report card is then forwarded to tl office of the Superintendent of Nurses. There it filed with the other daily reports of that individu nurse for the current week. NURSES' WEEKLY RECORD. Sec. 258. At the close of each week, the tota of the various items in the summary on the daily i ports are entered on a weekly record sheet (For 98 L), in the office of the Superintendent of Nurs< A separate sheet is kept for each district nurse, ai It shows at a glance the amount and kind of wo being done by each nurse. Each sheet covers a peri of fifty- two weeks. DIVISION OF VENEREAL AND VETERINARY DISEASES. Sec. 2,59. The Division of Venereal and Veterina Diseases is charged with the registration and sanita supervision of syphilis and gonorrhoea, conducti Diagnostic Clinics for these diseases: the sanita supervision of glanders, rabies and other infectio diseases in animals ; it conducts Anti-rabic Clinics i the administration of anti-rabic treatment; and a) conducts the Serological Laboratory. CHIEF OF DIVISION. Sec. 260. The Chief of Division exercises gene] supervision over all matters pertaining to the wc of his division throughout the city. He submits weekly report (Form 254 L) of the work of the Di sion. Ids I VENEREAL DISEASES. Sec. 2G1. On February 20, 1912, the Board of lealth of the Department of Health of New York yity adopted the following resolutions : On and after May 1, 1912, the superintendents or ther officers in charge of all public institutions such .8 hospitals, dispensaries, clinics, homes, asylums, haritable and correctional institutions, including all Qstitutions which are supported in whole or in part y voluntary contributions, are required to report romptly the name, sex, age, nationality, race, marital tate and address of every patient under observation buffering from syphilis, in every stage ; chancroid, or 'onorrhoeal infection of every kind (including gonor- hoeal arthritis), stating the name, character, stage nd duration of the infection, and the date and source f contraction of the infection, if obtainable. All physicians are requested to furnish similar in- ijrmation concerning private patients under their care, xcepting that the name and address of the patient eed not be reported. Cases of venereal disease are ntered in the Journal of Infectious Diseases (Form LL), which is furnished to every institution (see ec. 122) ; at stated intervals an institution inspector alls and copies the information on report cards Form 191 L), which are forwarded to the Division f Venereal Diseases. All physicians in New York ity have been requested by letter, to report their ises of venereal disease, a report card accompanying ich letter. REGISTRATION. Sec. 262. The reports of venereal diseases are filed I a special envelope (Form 168 L) and kept under 199 lock and key. The institution reports are filed alpha- betically according to the name of the patient. The cases reported by the private phj'^sicians are givec a case number for identification purposes, by which they are filed. The receipt of such cases is acknowl edged (Form 51 L), the physician being given th( case number for future reference. A daily journal is kept of cases of venereal disease reported by physi cians and institutions. INSPECTION OF CASES. Sec. 263. All complaints regarding cases of venerea diseases are immediately investigated by an inspec tor of the Department, who submits a written repor (Form 3L). No further action is taken in case; found to be under the care of private physicians o regularly attending dispensaries. Cases under n< medical supervision are advised by the inspector t attend the Diagnostic Clinics of the Department o Health. Here, according to their circumstances, the are sent to dispensaries or given lists of private phj sicians living in the neighborhood of their home, froi whom to receive treatment. MEDICAL ADVISER. Sec. 264. The co-operation of the Bureau of Socif Hygiene has made it possible to appoint a Medici Adviser as well as to conduct a Serological Laborator; The Medical Adviser sees only those patients wb having no physician (notices to this effect being sei to physicians) (Form 169 L), come to the Departmei f of Health for advice. Under no circumstances does I see or interview patients recommended by physiciai to the Department for the purpose of having Wasse 200 I nann or complement fixation tests made, unless the jlij^sicians sending the patients, specifically ask that )atients be advised, or directed to clinics, etc. If patients who have no physicians come to the De- 3artmeut, these patients are given lists of private Dhysicians or sent to approved Clinics according to heir circumstances. [Note. — Clinics on the "approved isf must come up to standards set by the Department )f Health. Clinics desiring to be listed are carefully nvestigated before approval is given.] The Medical Adviser acts as a clearing house for oatients having venereal diseases. Under no circum- Hances is any treatment given. He advises patients 3n sex subjects and informs them where to obtain sex literature and the cost thereof. Patients are also ?iven leaflets of advice [(Syphilis, Form 224 L; Gonorrhoea, Form 223 L) and a Circular of Informa- ;ion Regarding Venereal Diseases (Form — L.)] DIAGNOSTIC CLINICS FOR VENEREAL DISEASES. Sec. 265. Diagnostic Clinics for venereal diseases ire held in Manhattan and Brooklyn. For addresses md hours see Directory (Sec. 2). At each clinic there is a physician, a nurse and a elerk. Patients are referred to these clinics for the Wassermann test for syphilis and the complement fixation test for gonorrhoea. Patients may also be referred to the Manhattan Day Clinic for examina- tion of freshly prepared specimens for the treponema pallidum. Only those patients who bring written re- ijuests from physicians or clinics are received for ex- 201 amination, and reports of the results of tests are sent only to the physicians referring the cases, and by mail only. All si^ecimens sent to the Serological Laboratory are entered iu a daily loose-leaf journal (Form 76 L) SEROLOGICAL LABORATORY. Sec. 266. A Serological Laboratory is maintained at Department Headquarters, 149 Centre Street, Man- hattan. The Laboratory consists of three examining rooms — a culture room, a sterilizing room and a room for the preparation of outfits for collecting specimens The Laboratory is open from 9 A. M. to 5 P. M, daily, Sundays and holidays excepted. In the Serological Laboratory are made, free ot charge, the following examinations for physicians and veterinarians: (a) the Wassermann test for syphilis : (b) the examination of smears for the presence ol gonococci ; (c) the complement fixation test for gon- orrheal infection; (d) the examination of freshly prepared preparations from the active lesions, for the treponema pallidum; (e) the complement fixatior test for glanders in horses. A daily journal is kepi of the work performed each day. Outfits, with full directions for obtaining specimens, can be had free at any of the Department Supply Stations. (See Sec. 318.) Serological specimens are prepared for examinatiou the day on which they are received, and examined the following day. Reports are made on the third day after the speci- mens are received at the Laboratory. At least five days should be allowed before a report is expected on 202 ;pecimens sent through Department supply stations. |jl results are entered on a daily list (Form 180 L). ' All information and all reports in connection with ersons sulfering from venereal diseases are regarded |s absolutely confidential and are not accessible to the ublic nor are such deemed public records. j WASSERMANN TEST FOR SYPHILIS. ■ Sec. 267. Outfits supplied to physicians for coUect- ■ag blood specimens for syphilis, consist of: (1) a terile needle; (2) a sterile tightly corked tube, all inclosed in a wooden box; (3) a history form 163 L), and (4) instructions for collecting blood pecimens (Form 233 L). ' The results of Wassermann tests are reported to l.hysicians by mail (Form 182 L). As the specimens of blood to be examined for the Vassermann reaction deteriorate very quickly, and should be examined at the earliest moment, they :.re issued only to those supply stations visited daily 'ly collectors of the Diagnosis Laboratory. The Wassermann outfits are relatively costly, and, iis is the case with other outfits supplied by the De- >artment of Health, many are never returned to the :iaboratory, being used by physicians and druggists or other than their intended purpose. The druggists jire, therefore, required to obtain a receipt from the ')hysician for each outfit issued. These receipts (Form 537 L), which are issued with the outfit, are for- varded through the collectors to the Laboratory. Should no specimen of blood be received at the Labor- itory within a few days, the physician is communi- *ated with by mail or telephone. 203 INTERPRETATION OF THE WASSERMANN READINGS. Section 208. xxxx means VERY STRONGLY POSITIVE. XXX means STRONGLY POSITIVE. XX means POSITIVE. X means WEAKLY POSITIVE. X means DOUBTFUL. -^means NEGATIVE. A diagnosis of sypliilis should never be read froil a weakly positive or doubtful reaction (x or x ), But in a known case of syphilis that has had specifi ired data ; on the reverse side are given instructions T obtaining the specimen. METHOD OF PREPARATION, EXAMINATION AND REPORTING. Sec. 304. At 7 A. M. of every week day except •lidays, the Manhattan and Brooklyn sputum speci- ,ens collected on the day before are prepared for amination. Brooklyn specimens are brought to the boratory in the evening after collection. Bronx, jeens and Richmond specimens and lists are pre- ired at 9 A. M. All slips, after they are marked id dated, are sterilized for one hour in an Arnold erilizer. 223 Two laboratory assistants are assigned to the dut of preparing the specimens. A moderately thin smea of selected portions of the sputum, representing i area two cover-glasses, is spread on a new glass slid< The "day" number is marked on the slide with a dif mond. The slides are dried on an Ehrlich plat( After they are dried and fixed they are covered sei arately with fresh carbol fuchsin water, and heate to steaming for five minutes. They are then washe in running water, decolorized in acid alcohol (3 pe cent hydrochloric acid in 70 per cent, alcohol), an counterstained with methylene blue. A blank lab( for marking result of examination is then affixec Watery, oily or dried samples receive special atter tion. Leaky or improperly preserved specimens ar not examined, notice of this fact being sent to th physician concerned (Form 173 L). The same is tru of specimens forwarded without the name and ac dress of the patient (Form 45 L) or of the attendiu physician (Form 247 L). Microscopical examinatioD begin at 9 A. M. Twelve laboratory assistants ar detailed for this work. A rapid, superficial examine tion is first made to exclude all specimens showing large number of tubercle bacilli. The remaining spec mens receive a millimetre search by the use of mechanical stage. ANTIFORMIN METHOD. Sec. 305. All specimens failing to show tubercl bacilli are examined by the antiformin method a follows : Five c. c. of the sputum in sputum jar as receive at Laboratory is mixed with an equal volume of ant formin, previously diluted with three parts of wate: 224 The sputum-antiformin mixture is then shaken for Dout fifteen minutes by means of a mechanical laker, and is allowed to stand until fluidification Is )mplete. The mixture is then diluted with an equal volume ; alcohol and centrifuged for half an hour. The ipernatant fluid is then poured off, more alcohol is ided, and the mixture recentrifuged. The latter :ep may be omitted if a good sediment is obtained fter the first centrifuging. Smears made from the sediment are stained as escribed above. REPORTS. Sec. S06. Results of examination are marked on le slide; also in the proper place on the slip, to- ether with the initials of the examiner. The terms sed for marking are "positive" and "negative." All lides are stored in a special cabinet twenty days. Vritten reports of positive results (Form 97 L) and f negative results (Form 39 L) are sent to the hysician. Every case whose sputum shows tubercle acilli, and every case which the attending physician risbes to be considered as tuberculosis despite ab- lence of tubercle bacilli, is reported to the proper [Jorough Office on a tuberculosis tally card (Form 26 L). All cases of children under sixteen years bowing tubercle bacilli are also reported to the Ex- cut ive Office. All slips, on completion of the examination and eporting of results, are forwarded to the proper Jorough Oflices, where they are filed in special en- elopes (Form 138 L). 225 TYPHOID FEVER. THE WIDAL REACTION. WIDAL OUTFIT. Sec. 307. The Widal outfit consists of the folio ing articles: A clean glass slide, in a wooden sli case, closed with a rubber band; a slip, giving i structions for obtaining the specimen (Form 1061 and for all necessary data ; and a circular of inform tion regarding the tests for typhoid fever, the ii portance of the disinfection of urine, etc. (For 34 L). The whole outfit is inclosed in an envelo] directed to the Diagnosis Laboratory (Form 143 L TECHNIC OF EXAMINATION. Sec. 308. The dried blood, diluted 1-40, is used t the reaction. A fresh bouillon culture of the typho" bacillus is prepared every night. On the followii morning this culture is tested for its motility ar its reaction to a known typhoid blood. The following system of indicating results on si is used : "positive" — a complete reaction with a dil tion of 1 to 40 within from thirty to sixty minutes "negative" — no reaction within the same time; "i complete" — partial clumping and partial loss < motility of bacilli. Written reports (Form 40 L) ai sent to the attending physician. Results are tel phoned from "laboratory" lists, on which are giv( telephone numbers and names of physicians; sli] are filed in Borough Offices in special envelop* (Form 14 L). When a case is terminated, the e: velopes are filed in the record envelope of the cas in the terminated case file in the Borough Office. 226 ft EHRLICH'S DIAZO REACTION. DIAZO OUTFIT. Sec. 809. The outfit consists of a stoppered glass vial; a slip for data (Form 159 L) ; and a circular of information (Form 34 L) — the whole inclosed in a screw-topped wooden box. TECHNIC OF EXAMINATION. Sec. 310. Presence or absence of the reaction is determined as follows : equal parts of the suspected urine are mixed with the following reagent — satu- rated solution of sulphanilic acid in 5 per cent, hy- drochloric acid, 40 parts ; 0.5 per cent, solution sodium nitrite, 1 part — and the mixture well shaken. On the addition of a few drops of ammonia a bril- liant rose-pink color appears when the reaction is present. The twelve hours' sediment is also char- acteristic, consisting of a dirty gray lower layer and a narrow dark olive green upper layer. The result ; is stated on the slip as "positive," "negative," or I. "doubtful." Results are reported and filed as in the case of Widal specimens. [Report blank (Form i; 161 L), filing envelope (Form 160 L)]. All typhoid specimens, bottles, slides and tubes are Hi disinfected in 1 to 20 carbolic acid on completion of /• examination. f * CIRCULAR OF INFORMATION. Sec. 311. With each written report is sent a copy 'i of the circular, "How to Avoid the Contraction and I Prevent the Spread of Typhoid Fever" (Form 227 178 L) , with the request that the attending physician give it or equivalent instructions to the family 6f the patient. EXAMINATIONS FOR MALARIAL ORGANISMS Sec. 312. Outfit consists of two glass slides, in a slide box; a Hagedorn needle; a slip (Form 166 L) for data giving all instructions for obtaining speci mens ; and a circular of information regarding mala ria (Form 33 L). A modified Nocht-Romanowsky method of staining the blood is used. Results of examinations are marked on slip, and reported to physicians by tele- phone and mail, as in the case of typhoid fever [Report blank (Form 165 L), filing envelope (Forn 167 L)]. CEREBRO-SPINAL MENINGITIS. Sec. 313. Outfit consists of a well-corked sterile; glass vial, slip (Form 188 L), and circular of infer mat ion (Form 196 L), all inclosed in a wooden screw- topped box. Specimens are stained with Loeffler'f methylene blue and by Gram's method. The pres- ence or absence of meningococci is reported to the physician by telephone and mail, as in the case oi typhoid fever. Report blank (Form 187 L), filin? envelope (Form 186 L). [Note. — The examination for gonococci, treponemc pallidum, and the performance of the complemen fixation tests for syphilis, gonorrhoea, and glanders are carried out in the Serological Laboratory of th( Division of Venereal Diseases.] 228 OLLECTION OF SPECIMENS AND SUPERVI- SION OF SUPPLY STATIONS. SUPPLY STATIONS. Sec. 314. Various pharmacies throughout New York ity keep on hand culture tubes, diagnostic outfits id diphtheria antitoxin and vaccine, supplied by le Department of Health. These pharmacies are aown as "supply stations." A full description of lese outfits and the various grades of antitoxin, to- other with a full list of supply stations, is found in le circular entitled "Work and Products of the iagnosis, Research and Vaccine Laboratories" (Form >5L). A list of the supply stations in condensed •rm is also given in a booklet (Form 206 L). These supply stations are of two kinds: (a) "Regular stations," which are visited daily ^ collectors and supplied directly by them (in all Droughs). (b) "Sub-stations," which obtain supplies on re- lisition (Form 148 L), forwarded by mail in di- eted envelope furnished for the purpose, or through e regular stations, and which deliver specimens ,.ily to the regular stations before the collector calls. 1 stations are visited at least once a month by sup- Y wagons, and the stock of supplies inspected and plenished. All requisitions after they are filled are stamped th the date and initials of the employee who put the order. They are then filed for reference. Supply stations are established on written appli- 229 cation to the Diagnosis Laboratory. Agreements re lating to the care of the stations must be signed ir duplicate (Form 15 L). A card index (Form 120 L) of all stations is kept This index records stock of every station on hand a each station. The monthly visits are also enterec on a large chart, from which the route of the suppl: wagon is laid out each day. The location and character of all supply station are indicated upon maps of the different Borough by means of colored tacks. STOCK OF SUPPLIES CARRIED BY STATIONS Sec. 315. Supplies carried by regular station (minimum) : Culture tubes i 2 Dozen Swabs 2 Dozen Culture envelopes 2 Dozen Typhoid outfits (Widal) 1 Dozen Typhoid outfits (Diazo) 1 Dozen Meningitis and malaria outfits, each V2 Dozen Gonococcus outfits V2 Dozen Sero-diagnostic outfits % Dozen Primary diphtheria blanks (Form 21L) 5 Dozen Later diphtheria blanks (Form 26L) ...5 Dozen Sputum jars 3 Dozen Sputum blanks (Form 38 L) 5 Dozen Antitoxin 6 Bottles Vaccine 10 Tubes 230 The blanks for Widal, Diazo, malaria and gonococ- jus specimens accompany each outfit. Supplies carried by sub-stations (minimum) : Culture tubes 12 Swabs ,12 Culture envelopes 12 Sputum jars 12 Typhoid outfits (Widal) 6 Typhoid outfits (Diazo) 6 Meningitis and malaria outfits, each.... 4 Gonococcus outfits 2 Sero-diagnostic outfits 2 Primary diphtheria blanks (Form 21 L). 12 Later diphtheria blanks (Form 26 L) 12 Sputum blanks (Form 38 L) 12 Antitoxin .i 6 Bottles Vaccine 10 Tubes The proprietors of sub-stations agree in writing ;Form 15 L) to deliver all specimens to regular tations at an appointed time each day, and to send or packages of new supplies within forty-eight hours fter notice has been received. Such notice is sent ly postal card (Form 145 L). DUTIES OF COLLECTORS. Sec. 316. Incubators, in which cultures may be ilaced at any hoar, are maintained in connection nth all the Borough Offices. One collector in each Borough, on completing his onnd, is designated to mark each culture tube and ts slip with a corresponding serial day number, to aake out the laboratory culture lists and place the 231 tubes in the incubator. The typhoid, sputum and ma- laria specimens are placed in the boxes provided therefor. The urine specimens are placed in the ice chest. When the collector places the culture tubes in the incubator at night, he notes its temperature on diph- theria culture list (P. M. temp degrees), and again when he removes the cultures on the following morning (A. M. temp degrees). In Brooklyn, Bronx, Queens and Richmond the collector also compares all diphtheria, malaria and typhoid slips with the Borough Office records to see if any previous examiDation has been made. Every morning the collectors bring tubes, slips and other specimens to the Diagnosis Laboratory in Manhat- tan, where they are examined. Collectors must leave the Borough Offices promptly and visit the supply stations according to schedule; in no instance is a station to be left before the sched- uled time. The collector always carries the hand-bag furnished by the Department and a full stock of supplies. Tele- phoning to supply stations to ask if there is any necessity to call is strictly forbidden under penalty of dismissal. The stock of supplies in each station is to be care- fully examined daily, especially the culture tubes, and all spoiled tubes must be replaced. If the number ol other outfits is deficient, it must be made up to the required amount. If packages for sub-stations remain at the regulai stations more than forty-eight hours, this fact U 232 I sported to the Assistant Director of the Diagnosis Laboratory. All carfare vouchers for the preceding month, prop- erly made out in duplicate and sworn to, are sub- mitted to the Assistant Director of the Diagnosis Laboratory on the first day of the month (Forma 243-244 L). A record of the daily expenditures of each collector is kept in a journal (24LL). In Manhattan the collectors report at the Diagnosis Laboratory daily at 3 :30 P. M., and put up all orders for supplies which may have been received during I the day for their stations. One collector in each Borough on his return from his rounds collects all specimens which have been ■•■: left in the cabinets located in the halls of the various Borough Offices. Special attention must be paid to the collection of all fumigation orders left at the supply stations by the district nurses and diagnos- ticians. These orders must be delivered to the proper officials in the Borough Offices on the same night im- mediately after the return of the collectors from their rounds. The collectors of Brooklyn, Bronx, Queens and Richmond report to the Diagnosis Laboratory with their specimens, as follows : Brooklyn, diphtheria . .1 8 :00 A. M. Bronx, all specimens 8 :30 A. M. Queens, all specimens Richmond, all specimens GENERAL RULES OF DIAGNOSIS LABORATORY. Sec. 317. Only workers in the laboratory, collec- tors, cleaners and officers of the Bureau are allowed 233 in the laboratory. All others must receive permis- sion from the Director of Bureau, or Assistant Di- rector of the Laboratory. All workers in the laboratory who have handled infected material of any kind must thoroughly wash their hands with soap and water and rinse them in 1 to 1,000 bichloride solution before leaving. No waste paper, nor wrappings of packages, etc., are to be tlirown on floor or desks. Baskets are pro- vided. All specimens must be sterilized as soon as pos- sible after preparation of slides, etc. [sputum slips after dating and numbering.] All towels are to be kept in towel clips attached to desks. All instruments and materials used must be put away neatly at the conclusion of the day's work and desks and glass slabs cleaned with 5 per cent, car- bolic acid (using cheese cloth, not towels). Each employee doing microscopical work is sup- plied with a microscope for his personal use. He is responsible for its condition, and when examinations are finished, must wipe oil from the objective witb lens paper (not towels), wipe off brass and lacquer, and replace instrument in his locker in the micro- scope cabinet, turning and removing the key. He must replace the key at his own expense, if lost. White suits are sent to the laundry every Monday. One bacteriological diagnostician must be con- stantly in the laboratory between 9 A. M. and 5 P. M. 234 P MANHATTAN COLLECTION ROUTES. Sec. 318. DAILY EOUTES. I. Bboadway and Sixth Avenue Route. P.M. Hegeman St. Nicholas Ave. & 180th St. 4 :05 Halper Broadway & 156th St 4 :10 Driesen Broadway & 144th St 4 :15 Dorb Broadway & 127th St 4:20 Riker Broadway & 110th St 4:30 Kerley Broadway & 102d St 4 :35 Tsheppe & Rieck Broadway & 91st St 4 :40 Hegeman Broadway & 80th St 4 :45 Pond, Bowes & Cart- wright Broadway & 70th St 4 :50 Boeddicker ,. .6th Ave. & 54th St 5 :10 Riker 6th Ave. & 28d St .5 :35 Bigelow 6th Ave. & 8th St 5 :45 Borough Office m Ninth Avenue Route. Raub ..St. Nicholas Ave. & 145th St.4 :00 Molwitz 8th Ave. & 144th St 4 :00 Sagal & Kaufman... 8th Ave. & 135th St 4:05 Hegeman 8th Ave. & 12oth St 4 :10 McCutchen 8th Ave. & 113th St 4:15 Reed ..( ....Columbus Ave. & 104th St.. 4:20 Taylor Columbus Ave. & 92d St 4:25 Buck Columbus Ave. & 92d St Spangenberg Columbus Ave. & 82d St 4 :30 Bauer Columbus Ave. & 69th St... 4:40 Jones & Leonard.... Columbus Ave. & 61st St 4:45 Roosevelt Hospital.. Columbus Ave. & 59th St... 4:50 I 23.5 P.M. James Stli Ave. & 44th St 5:00 Blomeier 9tb Ave. & 34th St 5:10 Golding 9th Ave. & 22d St 5:20 Katz , 9th Ave. & 14th St .5:25 Flower Hudson & Barrow Sts 5 :35 Knapp Hudson & King Sts 5 :40 Herzenberg 40 Grand St., nr. Thompson . 5 :50 Borough Office Madison and Foukth Avenue Route. Robbins Lenox Ave. & 137th St 4 :00 Hegeman Lenox Ave. & 125th St 4 :10 Diamond Lenox Ave. & 114th St 4:15 Perla i. . . .i. Madison Ave. & 109th St 4 :20 MtSinai Dispensary .Madison Ave. & 100th St 4:25 Simetz Madison Ave. & 97th St 4 :25 Dauscha .Madison Ave. & 91st St 4:30 Cassebeer ^ladison Ave. & 75th St.... 4:40 Timmermann Park Ave. & 65th St 4:50 Kalish Madison Ave. & 59th St 4:5.5 Munsch, Protzman & Co Madison Ave. & 48th St 5:00 Reeder ^ Madison Ave. & 48th St 5:00 Schoonmaker Park Ave. & 42d St 5:05 Caswell, Massey Co.. 4th Ave. & 33d St 5:10 Bagoe 4th Ave. & 29th St 5 :15 Kalish 4th Ave. & 23d St 5:20 Borough Office Thibd Avenue Route. Budelman Madison Ave. & 131st St 4 :00 Sayer . .i 125th St. & 3d Ave 4 :05 Trau 116th St. & 3d Ave .4 :10 Aronstamn 3d Ave. & 105th St 4 :15 23G P.M. Frohwein 3d Ave. & 91st St '. .4 :25 Lascofe Lexington Ave. & 83d St . . .4 :35 Zinckgraf i 3d Ave. & 67th St 4 :45 iVauheim Lexington Ave. & oQtli St. . .4 :50 Edlich 3d Ave. & 52d St 4 :55 The Goldlust Pharmacy 3d Ave. & 88th St 3 :45 Du Gay i Lexington Ave. & 34th St. . .5:10 Keating 3d Ave. & 29th St 5 :15 Sultan .3d Ave. & 23d St 5 :20 (Valters 2d Ave. & 13th St 5 :25 ^emser 1st Ave. & 5th St ..5:30 Borough Office ..... LowEK East Side Route. Miner Spring St. & Bowery 4:00 tValker Broome & Ludlow Sts 4 :10 .ja. Pinto Grand & Mott Sts A :15 Juarini & Candela..New Bowery & Roosevelt. . .4:30 liipset , Henry & Pike Sts 4:35 ilamelok E. Broadway & Clinton St. .4:40 decker Broome & Cannon Sts 4 :50 Joldblatt E. Houston & Cannon Sts . . .4 :.55 xoldberg • ,. ..E. Houston & Clinton Sts... .5:00 lobinson 10th St. & Avenue C 5 :15 Veiss 9th St. & 2d Ave 5 :25 Jullenbach . .( . .4th Ave. & Astor PI 5 :30 Borough Office Sunday and Holiday Route. I. West. Ie;?eman 180th St. & St. Nicholas Ave. 3 :00 lalper Broadway & 156th St 3:10 237 P.M Dorb Broadway & 127th St 3:2< Riker Broadway & 110th St 3:21 Reed Columbus Ave. & 104th St. .3:31 Spangenberg Columbus Ave. & 82d St. . . .3 :4{ Bauer Columbus Ave. & 69th St. . .3 :5I Dougan & Merritt. ..Columbus Ave. & 61st St... 3:5 James . .8th Ave. & 44th St. 4 :0! Goldmg ,. . . .,.9th Ave. & 22d St 4 :li Riker 6th Ave. & 28d St 4:2( Bigelow 6th Ave. & 8th St 4:i Knapp , Hudson & King Sts ,. A: Herzenberg Grand St., nr. Thompson . . .4 :& Borough Office II. East. Raub St. Nicholas Ave. & 145th St. 3 :0 Sagal & Kaufman. . .8th Ave. & 135th St 3:1 Hegeman 8th Ave. & 125th St 3:1 Hegeman Xenox Ave. & 125th St 3:2 Sayer 125th St. & 3d Ave 3:2 Trau 3d Ave. & 116th St.. 3:3 Aronstamn 8d Ave. & 105th St 3:3 Lascofe 83d St. & Lexington Ave... 3:4 Zinckgraf ,. . .8d Ave. & 67th St 3:5 Lourle & Stoller 59th St. & Lexington Ave..4K) Kalish , Madison Ave. & 59tb St 4 :C Schoonmaker 42d St., nr. Park Ave 4:1 Caswell & Massey Co.4th Ave. & 33d St 4 :2 Kalish ) 4th Ave. & 23d St 4:2 Miner „,. Spring & Bowery ,..4:; Mamelok E. Broadway & Clinton St.. 4:4 Goldblatt E. Houston & Cannon Sts..4:E Walter 2d Ave. & 13th St 5:C Borough Office ..... 238 M \A H 'e It BRONX COLLECTION ROUTES. Sec. 319. DAILY. I. West. )epartment of Health P. M. Tuberculosis ClinicE. 139tli St. & New Brook Ave 4:00 •Icker 138tii St. & Brown PI 4:05 >itarro • 590 Morris Ave., bet. loOth & 151st Sts 4:10 Vurm .....Morris Ave. & 162d St 4:25 )ibella .Plimpton & Boscobel Aves. .4 :40 losenbaum Fordbam Rd. & Jerome Ave. 4 :55 ones 1 Fordham Rd. & Marion Ave . 5 :(J5 lassell Webster Ave. & 200th St . . . 5 :15 i^incke ..White Plains Ave. & Gun Hill Rd .5:25 liller E. 177th St. & Park Ave 5 :45 ironx Office, Depart- ment of Health... 3d Ave. & St. Paul's PI 5:55 I II. East. ierson .. ., 78 Westchester Sq 4 :00 filler Boston Rd. & E. 177th St... 4:15 larass Hoe & Freeman Sts 4 :25 L-Re-Co. Pharmacy. . Westchester Ave. & Simpson St 4:35 lothman Westchester & Tinton Aves. 4:45 Joldwater 3d Ave. & 142d St 5:00 legeman , 3d Ave. & 149th St 5 :05 Vernert 1272 Boston Rd. ( McKinley Square) 5 :35 5ames 3d Ave. & 161st St.., ...5:40 239 IB ••^11 Jl ll' Ir Huther , 3d Ave. & 169th St 5 :^ "^ Bronx Office, Depart- '^ ment of Health... St. Paul's PI. & Sd Ave 5:E m Sunday and Holiday Routes. Miller . ., Park Ave. & E. 177th St. . . .3:4 Rosenbaum Fordham Rd. & Jerome Ave. 4^ Jones .Fordham Rd. & Marion Ave. 4: I'incke Gun Hill Rd. & White Plains Ave 4:2 Pierson Westchester Sq , 4:1 Miller . ., Boston Rd. & E. 177th St. . .5 A-Re-Co. Pharmacy.. Westchester Ave. & Simpson St .5:3 Rothman Tinton & Westchester Aves.5:S Hegeman 149th St. & 3d Ave 5 :? Sames 161st St. & 3d Ave 5:4 Huther 169th St. & 3d Ave 5:t Bronx Office, Depart- ment of Health... 3d Ave. & St. Paul's PI 6:C BROOKLYN COLLECTION ROUTES. See. 320. daily. Route No. 1. Whitley 91st St. & 3d Ave 4:( Wolf .69th St. & 3d Ave 4:1 Osborn 54th St. & 5th Ave 4 :2 Osborn 46th St. & 3d Ave 4:5 Cantor 337 Van Brunt St 4:4 Kemble Carroll & Henry Sts ,...4:S Nehrbas , 316 Court St 5:C Raid 300 Clinton St 5:C 240 JA P.M. aydenreich 167 Atlantic Ave 5 :15 imb , 84 Court St , 5:20 Iker 264 Fulton St 5:25 Bid 135 Sands St 5:35 apartment of HealthFleet & Willoughby Sts Route No. 2. ammond ...73d St. & 13tli Ave 4:00 ^ahlstadt 86tli St. & 18th Ave 4 :10 iwler 1401 60tli St. (Mth Ave.) . . .4 :25 alke Bros 53d St. & 13th Ave 4 :30 oamer , 39th St. & Ft. Hamilton Ave. 4 :50 all & Co 5th Ave. & 19th St 5:10 sborn 11th St. & 5th Ave. ., 5 :20 bramson Drug Co. .President St. & 5th Ave. . . .5 :30 apartment of HealthFleet & Willoughby Sts Route No. 3. jrager 757 Gravesend Ave 4 :00 ncelin Surf Ave. & W. 16th St 4 :30 eiss 310 Neptune Ave., Coney Isl.4 :40 Dhnston E. 14th St. & Kings Highway .4 :5.5 randenberg Coney Island Ave. & Cortel- you Rd 5:05 aymow Beverly Rd. & Coney Island Ave 5:10 respect Drug Co. ..Prospect Ave., cor. Reeve PI. 5:20 ordon 15th St. & 7th Ave 5:35 oulsen 9th St. & 7th Ave 5:40 'epartment of HealthFleet & Willoughby Sts Route No. 4. Mlberger 540 Flatbush Ave 4:00 jiutler 883 Flatbush Ave 4:05 241 1 P.M Hill 1098 Flatbush Ave 4:1.E Hunter 1538 Flatbush Ave 4t:2l Rappaport 1733 Nostrand Ave 4 :3E Waif ram 1292-94 Nostrand Ave 4:4E Dannliardt .Rogers Ave., cor. Midwood St.4 :5E Bancroft 712 Nostrand Ave 5:1C Bancroft Bergen St. & Franklin Ave. .5 :15 Wilson etli & Flatbush Aves 5 :25 Vinnicombe 44 Flatbush Ave 5 :3.5, Department of HealthFleet & Willoughby Sts Route No. 5. Quasman ...Fulton St. & Crescent Ave. .4:00 Chamberlain & Co... 3079 Fulton St 4: Mindel 2789 Atlantic Ave 4:15 Werner 2592 Atlantic Ave 4:20 Katz , Pitkin Ave. & Chester St 4:30 Benjamin Fulton St. & Rockaway Ave. 4:50 Balzheiser Fulton St. & Saratoga Ave. .5 :00 Rohrer Drug Co.... Sumner Ave. & Decatur St.. 5:10 Cadman Tompkins Ave. & Fulton St.5 :15 Pfister & Setterley. .1293 Fulton St 5 :20 Malkovsky Fulton St. & Wash'ton Ave.5 :30 Marsland 19 Greene Ave 5 :3.5 Department of HealthFleet & Willoughby Sts Route No. 6. Wesch Wyckofif & Myrtle Aves 4 :00 Claassen Myrtle & Knickerbocker Avs . 4 :05 Wendler Palmetto St. & Central Ave.4 :10 Heimerzheim 567 Central Ave 4 :15 Stein Broadway & Halsey St 4:20 Weber Broadway & Gates Ave 4 :30 Probst Ralph Ave. & Halsey St 4 :35 242 P.M. ettle 895 Gates Ave 4:40 ayden ...1189 Broadway 4:50 cheidt 948-52 Broadway 5 :00 ussensehidt Bedford & Myrtle Aves 5 :15 ;iopsch Cumberland St. & Myrtle Ave 5:25 epartment of HealthFleet & Willoughby Sts Route No. 7. rmsburg Drug Co..S. 4tli St. & Bedford Ave... 4:05 ossler & Hauck N. 6tb St. & Driggg Ave 4:10 >pper 937 Manhattan Ave 4 :20