iltlmaitte EDWARD R. KRUMBIEGEL, M. D. Commissioner of Health purpose of this little pamphlet is to give ESgj ||i to interested persons some information con- cerning the organization of the Milwaukee Department and to describe the various types of services, which the Health Depart- ment offers to the Milwaukee public. It is hoped that the pamphlet will be of assistance to the general public and likewise to the various schools, clubs and organizations that are interested in the study of civic problems and public service. COOPERATING AGENCIES EMERGENCY HOSPITAL Accidents Sudden Illness Emergency Service for the South Side Investigation and Research Chemical Food, Water, Gas Drugs and Poisons Beverages, Dairy Products Bacteriological Cultures, Blood Tests Smears, Food Poisoning Water and Milk Sanitation Laboratory Diagnosis Association of Commerce County Medical Society County Dental Society Milwaukee Hospital Assn. LABORATORIES Examinations Cooperation with Physicians Police Social Agencies State and U. S. Health Service Social Hygiene Instructor VENEREAL DISEASE THE MILWAUKEE HEALTH DEPARTMENT Deputy Commissioner of Health Administration Accounting Publications, Exhibits, Information, Lectures Birth Records 1893 Marriage Records 1897 Death Records 1870 Registry of Physicians, Midwives, Undertakers Reports to Commission- er, Washington, and State Health Dept. COMMISSIONER OF HEALTH VITAL STATISTICS Food Staff Manufacture Distribution and Sale of Food, Milk and Beverages Sanitation Staff 3 Stations 2 sq. mi. per Inspector 30,000 people per Inspector INSPECTION City Hall Clinic North Side Clinic South Side Clinic Urban League Clinic School Clinics Fresh Air Classes Home Supervision TUBER- CULOSIS 3 Stations 79 Districts Special Supervisors Child Welfare Tuberculosis Contagious Disease School Hygiene Home Hygiene and Nursing Instructors COOPERATING AGENCIES NURSING County Institutions Visiting Nurse Association Wis. Anti-Tuberculosis Assn. Milwaukee Safety Commission COMMUNICABLE DISEASE and SCHOOL HYGIENE Communicable Diseases Diagnosis Quarantine Placarding Prevention South View Hospital—250 Beds School Hygiene School Physicians Dental Hygienists 3 Dental Clinics Nutrition Instructor Preschool Clinics Baby Clinics Day Nurseries Baby Boarding Homes CHILD WELFARE THE MILWAUKEE HEALTH DEPARTMENT GENERAL ORGANIZATION In its general organization the Milwaukee Health Department is headed by the Commissioner of Health, who is appointed by the Mayor of the city and con- firmed by the Common Council for a term of four years. The Commissioner of Health appoints a Deputy Commissioner of Health, who is his personal appointee and is responsible directly to the Commissioner of Health. The position of Deputy Commissioner of Health is the only position in the Health Department which is not a civil service position. All the remaining employees of the department are appointed from lists submitted by the City Service Commission and the incumbents of these appointments, after serving a six months’ period of probation, may only be removed for cause. The Health Department is organized into three bureaus and six divisions. These bureaus and divi- sions are as follows: The first bureau is the Bureau of Communicable Diseases and School Hygiene. This bureau consists of three divisions, the Division of Communicable Dis- eases, whose function is primarily the prevention and control of communicable diseases, the Division of School Hygiene, which has charge of the health of school children, and the South View Hospital where communicable diseases are given hospital care and treatment. 1 The second bureau is the Bureau of Inspection. There are three divisions of this bureau. First, the Division of Food Inspection, which supervises the sale and distribution of all types of food in the city. The second division is the Division of Milk Inspec- tion, which is charged with the supervision of the milk supply of the community, and the third division is the Division of Sanitary Inspection, which is charged with the control of general sanitary condi- tions in the city and the abatement of nuisances. The last bureau is the Bureau of Laboratories. This bureau has two divisions, the Bacteriological Laboratory, whose principal functions are the bacte- riological investigations of milk, water and commu- nicable disease, and the Chemical Laboratory, which has charge of the chemical work involved in the super- vision of food, gas, drugs, beverages and other chem- ical problems. In addition to these three bureaus, there are six other divisions. The Division of Nurses supplies all of the public health nursing service for the various divisions and bureaus. In other words, the public health nurses of the city give general nursing service in their individual districts. The Division of Child Welfare is concerned with the conservation of infant life and the health of children below school age. The Division of Tuberculosis is responsible for the control of tuberculosis by means of education, 2 diagnostic services in clinics and schools, and super- vision of tuberculosis cases and contacts. The Division of Venereal Disease conducts diag- nostic clinics and social hygiene programs. It co- operates with the medical profession, courts, police and sheriff’s office, social welfare agencies, and other organizations interested in the control of venereal disease. The Division of Vital Statistics has charge of the records of births, deaths and marriages, and com- piles statistics related thereto. The Johnston Emergency Hospital, located on the south side, cares for emergency cases arising in that part of the city. Following this general survey of the organization of the department, each bureau and division of the department will be described in further detail. ADMINISTRATION The administration division, as has already been stated, is headed by the Commissioner of Health. He exercises general supervision over all the activities of the department and is responsible for departmental policies. The Health Commissioner is charged with all the statutory provisions and powers that are vested in local boards of health in the other commu- nities of the state. He makes all the appointments in 3 the department in accordance with the rules of the City Service Commission and is the responsible head of the department. The various educational activities of the depart- ment are centered in the Administration Division. Here are prepared all of the various publications issued by the department, including the department bulletins, posters, and other publications. Special health campaigns are also planned here. The Administration Division also organizes and prepares the courses of instruction that are required of department members and secures the instruction in these courses. Lectures, health talks and radio talks are likewise prepared here. The preparation of the budget and the adminis- tration of the financial needs of the department are directed through the Administration office, and gen- eral supervision over all the activities of the depart- ment is maintained here. DIVISION OF COMMUNICABLE DISEASES The prevention of communicable diseases is de- pendent upon the prompt isolation of cases and car- riers, and wherever possible upon the immunization of the population againt certain diseases — smallpox, diphtheria, typhoid fever, whooping cough and scarlet fever. 4 To secure prompt isolation of cases of communi- cable disease requires that the Health Department have knowledge of their location. This knowledge is obtained by the reports received and investigations made. The reports of actual and suspected cases of communicable disease are received by telephone, post card and letter from the family physician in attend- ance, parents without a doctor who report their cases to the Health Department, from neighbors, school principals, teachers, Health Department doctors and nurses out in the field, and anyone who has reason to suspect that a certain person may have a commu- nicable disease. Some cases of communicable disease are detected by the Health Department doctors and nurses through inspection in the schools, and many are found by the nurses when making their absentee calls. Some cases are found by the inspectors in their work in the dis- trict. The office of the communicable disease division upon receiving the report of suspected or actual cases of communicable disease, takes action as follows: Cases reported as SUSPECTED, or cases reported by PARENTS or NEIGHBORS are investigated by the Health Department to determine if they are actual cases or not. Some cases are investigated by the Health Department nurse, suspected cases of diph- theria being cultured. In all those cases requiring the 5 attention of a physician, where there is none in attend- ance, a diagnostician of the Health Department makes the call. The communicable disease office upon the receipt of a report of a definite case of communicable disease makes out the necessary records and papers, and the case is then either quarantined at home, taken to the hospital, or placarded. Quarantine and Placarding: General quarantine is established by an inspector of the Health Department after visiting the home, notifying the family and placing a quarantine placard in a conspicuous place on the front and rear doors of the house. Modification or change in the quarantine, the taking of cultures, and giving of further instruction is done by the nurse. In a home that is quarantined, no one is allowed to enter or leave the quarantined area, except the attending physician, graduate nurse in attendance on the case, clergyman, and representative of the Health Department, unless special permission has been given by the Health Department. During the period of quarantine calls are made by the inspector or nurse in the district to see that 6 proper quarantine is being observed, and to deter- mine if the family needs groceries, etc. The following diseases are required by the State Board of Health to be quarantined for the specified length of time: Diphtheria cases are quarantined for ten days from date of report and until two successive negative nose and throat cultures, taken not less than twenty- four hours apart, are obtained, and the necessary terminal disinfection has been done. Diphtheria carriers exposed to diphtheria or pre- senting history of illness are quarantined five days and until two successive negative nose and throat cultures are obtained. Carriers not exposed to diph- theria with no history of illness are isolated (not quarantined) until two negative cultures are ob- tained. Scarlet Fever cases (mild cases) are quarantined for three weeks; all others are quarantined four or more weeks until all indications of communicability have ceased, and disinfection of the person and premises has been done. Smallpox cases are quarantined until all crusts and scales have fallen off, and the disinfection of the patient and premises has been done. Cases of Infantile Paralysis, or Poliomyelitis, are quarantined for at least three weeks from the time of report, and until the patient and premises have been thoroughly disinfected. Cases of Cerebro Spinal Meningitis (Epidemic) are quarantined for at least two weeks from the time of report, and until the temperature is normal, and the infected rooms have been thoroughly cleaned. 7 Instructions concerning terminal disinfection of the rooms are given by the Health Department nurse when the cases are ready for release. The necessary disinfection must be done by the people in quar- antine. Placarding: The State Board of Health requires that homes containing cases of certain diseases be placarded. Placarding requires that a person having a commu- nicable disease be isolated on the premises until re- leased. Adult members of the family, who are not ill, are not held under restriction and may come and go as they please. Well children in the home are not held under restriction, with the exception of measles con- tacts. Well children who have never had measles must not go to school for two weeks from the date of the last exposure, dating such exposure from the beginning of the rash in the last case to which the person was exposed. Cases of German Measles are placarded for one week from date of report and until recovery. Cases of Measles are placarded for two weeks from date of report. Cases of Chicken Pox are placarded for two weeks from date of report, and until complete recovery. Cases of Mumps are placarded for two weeks from date of report. Cases of Whooping Cough are placarded for four weeks from date of report, provided this period is not less than six weeks from beginning of catarrhal symptoms. 8 Cases of Typhoid Fever and paratyphoid fever are placarded during the course of the disease and for one week after all clinical symptoms have subsided and until two specimens each of feces and urine, passed at intervals of not less than five days, have been examined in an approved laboratory. A per- son must not engage in the handling of food prod- ucts until two such successive specimens have been found negative. Cases of Influenza are placarded until the tempera- ture of the patient has been normal for at least four days. Cases of Influenza are not placarded unless epidemic conditions prevail. Cases of measles, German measles, chicken pox, whooping cough, mumps and influenza are placarded by the inspectors. Cases of typhoid fever and para- typhoid fever are placarded by the Health Depart- ment nurses, who give the necessary instructions in regard to disinfection so as to avoid the spread of this disease to other members of the family. The removal of placards for measles, German measles, whooping cough and mumps is done by the inspectors when the period for placarding has ex- pired. The placards for chicken pox, typhoid fever and paratyphoid fever are removed by the nurses after the necessary time has expired, and the cases have fully recovered. H os pitalization: Many cases of communicable disease demand hos- pital care, either because of the severity of the case or because it is impractical for the patients to remain at 9 home. To meet the demand for hospital care, the City of Milwaukee maintains a contagious disease hospital known as South View Hospital, located on Mitchell Street at South 23rd Street. This hospital is maintained for the benefit of the taxpayers of the city. Any resident of the city is entitled to medical care and treatment without cost while at the hospital. South View Hospital has a capacity of 250 beds. Patients are treated in separate wards and rooms under the most stringent aseptic precautions. The hospital is well equipped, so that patients with com- municable diseases can have the best of attention and care. Medical care of all patients in the hospital is ad- ministered by a medical director and an assistant medical director, assisted by two internes. Surgeons or consultants are called in exceptional cases, as necessity requires. The supervision of matters pertaining to the ad- ministration of the hospital and the nursing care is entrusted to the superintendent, who is also the social service director. The nursing care is given by grad- uate nurses. During the absence of the medical di- rector, the assistant medical director is in full charge of the hospital care of the patients. Visiting of patients while at the hospital is neces- sarily limited because of the contagious character of 10 the diseases admitted. There is no visiting on Satur- day and Sunday, unless the patient is critically ill or if, for some special urgent reason, an appointment has been made. Parents may visit once during the first week while the patient is in the hospital and once a week thereafter. A married male patient may be visited once a week by his wife, a married female patient by her husband. Visiting hours are from 2:30 to 4:30 P. M. Special precautions are taken to pro- tect persons visiting the patients so that they will in no way come in contact with those ill with a com- municable disease. Information concerning the condition of a patient while at the hospital can be obtained by calling the hospital per telephone, Mitchell 3590. Phone calls should be made between 8:00 A. M. and 6:30 P. M. For the convenience of the public a medical social service worker is on duty. It is one of her special functions to give out information pertaining to the condition of patients. Relatives are requested not to bring the following articles to patients: food, including fruit and candy; gum, crayons, pencils, toys with sharp points or sur- faces, balls, tops, or musical instruments. Patients are brought to the hospital in the hospi- tal ambulance. The ambulance personnel consists of a graduate nurse, a male attendant and a driver. The hospital has already cared for as many as 2,696 patients in one year. Many lives are saved an- nually, not to speak of other benefits derived. Prevention of Smallpox: Vaccination for the prevention of smallpox is an old procedure, and has been in use for many years. It has definitely proven its worth since 1796 when it was first introduced by Dr. Jenner in England. The value of this procedure was definitely proved in the City of Milwaukee during the epidemic of 1925 when over 400,000 vaccinations were done. No person successfully vaccinated within the previous five years developed smallpox during that epidemic. Of the 386 individuals who developed smallpox, 327 had never been successfully vaccinated. The Health De- partment at intervals throughout the year offers free vaccination in the schools and at various clinics in the City of Milwaukee. As a result of the State Board of Health rule requiring smallpox contacts to be vaccinated or quarantined, and that children be vaccinated or excluded from school for two weeks whenever a case of smallpox appears in the school district, it is frequently necessary for the Health De- partment to vaccinate in schools, factories and other public places. This vaccination is done by physicians of the Health Department. Prevention of Diphtheria: The prevention of diphtheria by the use of toxin antitoxin was introduced into the City of Milwaukee in 1922. This preventive work was in accordance with the type of practice introduced in other cities, New 12 York City being the pioneer in this held, having be- gun the work in the year 1913. Children from six months to ten or twelve years of age are most likely to contract the disease, the highest mortality occur- ring among children from six months to six years. To reach the largest number of children, the schools offered the best opportunity, and so with the coopera- tion of the school authorities toxin antitoxin was in- troduced into the schools. Circular letters explaining toxin antitoxin, together with permission cards, were given to the school children to take home, and if the parents wished to have the children immunized, all that was necessary was to sign the permission card, and the children received the protection without charge. The toxin antitoxin was given once a week for three weeks, and in a large proportion of cases immunity from diphtheria developed within a few months’ time. After introduction of the toxin antitoxin work into the schools, efforts were made to reach the pre- school children, or children six months to six years of age, because the highest mortality occurs in this age group. The work was done by giving toxin anti- toxin in the Child Welfare Stations, as well as in the various clinics. Circular letters were sent to mothers and nurses made home calls urging that children be immunized either by the family physician, or at one of the Health Department clinics or stations. More recently an alum-precipitated toxoid was introduced for the prevention of diphtheria. Only one injection of this material is required, and a higher percentage of immune persons results than with 13 toxin antitoxin. The alum-precipitated toxoid con- tains no serum and its use does not result in sensitiza- tion to serum. The protection does not develop imme- diately, but once developed, it lasts for years. Three months after toxoid has been given chil- dren are given a Schick Test to determine whether immunity has developed. Parents must sign permis- sion cards if they wish to have children Schick tested after they have received toxoid. This work is done by the physicians and nurses of the Health Department. Of the thousands of immu- nizations performed in Milwaukee there has not been a single untoward result. In 1921, the year before diphtheria immunization was offered in Milwaukee by the Health Department, there were 1,404 cases of diphtheria with 84 deaths. In 1939 there was only one case with no deaths. Prevention of Scarlet Fever: The prevention of scarlet fever by use of scarlet fever toxin for immunization was introduced in the Health Department in 1934. This preventive work was adopted in accordance with the Dick method of immunization introduced in 1924. The Dick Test is given to determine susceptibility to the disease. Posi- tive reactors to the Dick Test are susceptible to scarlet 14 fever, and are given the opportunity for immuniza- tion which consists of a graduated series of doses of scarlet fever toxin, five doses given at weekly inter- vals. Those who receive the immunization are later given an opportunity to have the Dick Test repeated, to determine whether immunity has resulted. Several hundred thousand Dick Tests, and many thousands of immunizations reported done elsewhere had proven the efficacy of this method of immuniza- tion before the procedure was adopted by the Health Department. The immunization is recommended, not only because an attack of scarlet fever may be so malignant as to cause death in a short time, but mainly because of the grave sequelae and complica- tions with which it may be attended. The effectiveness of this method of immunization, and the duration of immunity is approximately equal to that conferred by diphtheria immunization with toxoid. Although immunization against scarlet fever was formerly given in the schools, this has been discon- tinued because the highest incidence of scarlet fever occurs in children between three and six years of age. Since the greatest amount of benefit can be obtained in children of pre-school age the Health Department is concentrating its efforts along these lines in the Child Welfare and Pre-school Clinics. 15 Protection Against Whooping Cough: More infants die of whooping cough than from any other contagious disease. Infants are susceptible to whooping cough from birth in contradistinction to many other contagious diseases in which there is generally an inherited immunity persisting for sev- eral months after birth. Immunization against whoop- ing cough, although not as effective as diphtheria immunization, is nevertheless a procedure to be rec- ommended as it will greatly reduce the incidence of this serious disease. Inoculations are given in the Child Welfare clinics of the Health Department as follows: The first injection is given in the left arm followed by a second injection in the right arm three weeks later. At the third visit, three weeks after the second injection, an inoculation is given in each arm. SCHOOL HYGIENE DIVISION Medical supervision in schools has the following for its objectives: a. Educating school children and the public in healthful living and in disease prevention. b. Providing the children with a healthy environ- ment. c. Detecting physical abnormalities and securing their correction. d. Finding transmissible diseases in their earliest stages and by proper measures preventing their spread to others. 16 e. Advising modifications in school work in indi- vidual cases where existing defects or diseases might be accentuated by unrestricted participa- tion in the usual school activities, such as ath* letics, gymnastics, etc. f. Advising special educational facilities for chil- dren with defective hearing, defective vision, orthopedic defects, etc. g. Assuring a physically efficient teaching staff. Organization and Methods: Milwaukee is one of the few cities in the United States where school hygiene activities are extended to all schools alike—to public, parochial and private— to grammar, high and vocational schools. For general health supervision in grammar schools, the city is divided into geographical districts, and a physician is assigned to each district. The physician calls at each school in his assigned district, in ac- cordance with a schedule prepared by the Director of School Hygiene. The school physician has general supervision of the hygiene and sanitation of school grounds and school buildings, and of the health and physical wel- fare of school children, teachers and janitors, in matters peculiar to the medical profession. The routine work of the physician with the per- sonnel of the school consists of two forms of exami- 17 nation. One is entitled, "Morning Inspection” (also conducted by nurses in the absence of the doctor), the other is termed "Physical Examination.” An instructor in nutrition prepares and issues to the children lessons on diet for each grade in the grammar schools and lectures to the children and school organizations on nutrition and proper foods. Morning Inspection: When the school doctor arrives at a school, each teacher is informed of his presence. The teachers then send to the doctor’s office all children who appear to be acutely afflicted, or who have been absent from school for three consecutive days. Those cases which the nurse wishes the doctor to see are also referred to him at this time. The doctor determines whether the child may safely remain in school, or whether the child should be excluded or excused. When "follow- up” is deemed advisable, the case is referred to the nurse. Whenever school sessions are interrupted for a week or longer, an individual inspection of all chil- dren attending school, except those in the senior high schools, trade schools and vocational school, is made on the re-opening of the schools. The following cases are excluded from school attendance: a. Children suffering from acute tonsillitis until all throat symptoms have completely dis- appeared. 18 b. Children with symptoms prodromal of any of the acute contagious diseases, or those who are not yet fully recovered from such disease. c. Children afflicted with impetigo, scabies (Itch), or ringworm not showing evidence of being under treatment. d. Diphtheria "Carriers.” e. Children suffering from active pulmonary tu- berculosis. f. Children having live pediculi (Lice). g. Children with contagious eye diseases. h. Children with live nits whose treatment has been persistently neglected. i. Children whose presence in the classroom is obnoxious to other children due to discharges or to unclean condition of body or clothing. When a case or a suspected case of infectious dis- ease reportable under the state law is discovered in a school during room inspection or routine morning inspection, the name and address of the afflicted child is telephoned to the Bureau of Contagious Diseases of the Health Department by the school physician before leaving the school, and this is later confirmed by the regular postal card report. When a case of diphtheria occurs in a room, all the children of the room and the teacher are cultured. When a case of scarlet fever occurs, each child in that classroom is inspected at least once by the school nurse. When two or more cases of scarlet fever occur in a room, daily inspections of children in that room are made by the nurse for one week. 19 Physical Examinations: In the elementary schools, a complete physical examination for the discovery of physical defects is routinely given every child at least once in two years. When a correctable defect is found, the parents of the child are informed of this fact on a suitable card, and a request for correction is made. A follow- up card is also given to the nurse. New Entrants9 Examinations All children in the morning kindergarten or first grade who have never been given a physical exami- nation in the school (new entrants), are examined by doctors rotated from school to school and especially chosen for this work. Parents are notified through the nurse as to the date and hour at which their child is to be examined, and are requested to be present during the examination. If the parent is present at the scheduled time, the child is given a stripped ex- amination in the presence of the parent. Any defects noted in the course of the examination are then dem- onstrated to the parent, and the need for correction, if any, explained. In the high schools, all 9th grade pupils are given complete physical examinations. A code for designating the degree of physical de- fect is used. 20 The Vocational School and Permit Children: Two physicians are assigned to the Vocational School for health supervision in that school, and also for the examination of children applying for a per- mit to work. Each physician devotes three hours per day to this work, one of them being on duty in the morning, the other in the afternoon. By order of the Industrial Commission of the state, all children between the ages of 14 and 18 applying for a permit to work in the city of Milwaukee must present a physical examination record issued by the School Hygiene Division before a permit can be obtained. Based on the findings resulting from this physical examination, recommendation is made to the Indus- trial Commission for the issuance of an unrestricted or a restricted permit, or the refusal of a permit. An unrestricted permit is recommended when the child is physically well and strong, and has had all physical defects, where such existed, corrected. A restricted permit is recommended in cases hav- ing correctable physical defects, and also in cases having physical defects which, in the judgment of the physician, should restrict the child to definite kinds and places of employment. Children working under restricted permits are re- examined at stated periods. The Industrial Commis- sion sends a written notice to the employer of the 21 child, directing that the child report to the physician on a specified date — usually on the day on which the child attends school. When the restriction is due to the presence of a heart lesion, epilepsy, respiratory abnormalities, etc., a permit, restricted as to job, is recommended and periodic examinations are made of these children during the permit age. When no conscientious effort is made to follow advice given as to the correction of defects, or if it is found that the work the child is then doing is having a deleterious effect on his health, recommendation is made to the commission to suspend or revoke the permit. Refusal of a permit is recommended when, in the judgment of the examining physician, the child is not in physical condition to enter the field of labor. The Handicapped Child: Children who, through physical or mental abnor- malities, fail to maintain the standard prescribed as normal in the educational system, or who do so with great difficulty, are given special attention. Among these are the physically weak and malnourished, those with defective vision and hearing, speech defects, heart lesions, the crippled and the mentally superior or subnormal. They are referred to special clinics either in the Health Department or at the dispensaries. 22 Eight open air classes are located in various schools and are intended for children who are tuber- culosis contacts, or who are suffering from certain heart diseases, chronic asthma and other bronchial conditions, certain nervous diseases, and severe mal- nutrition. Such children are brought to the attention of the school physician who performs a preliminary examination and, if indicated, refers them for exami- nation to the Tuberculosis Division. Transfers to open air classes are made only on recommendation of the Tuberculosis Division. Five defective vision classes are located in the schools of Milwaukee. These classes are intended not only for blind children, but for those whose vision is so defective that normal accomplishment in a regu- lar class room is difficult or impossible. Admission to these classes is effected on recommendation of the office of the Director of School Hygiene after exami- nation by specialists in the field of vision. The Paul Binner School is designed to serve deaf children as well as those whose hearing is so defec- tive as to make teaching in the regular class room difficult or impossible. Children are admitted to this school on recommendation of the office of the School Hygiene Division after examination by a specialist in ear diseases. Crippled children and those with extreme heart ailments are placed in the Gaenslen School. Many crippled children are recommended for enrollment after examination by the School Hygiene Division. 23 Behavior and mental problems are examined by the psychologist of the Department of Schools or, after physical examination in the office of the School Hygiene Division, are taken to the Milwaukee County Guidance Clinic for advice as to disposition. Children who are unable to attend school because of some physical handicap are examined in their homes and recommendation is made as to the advisa- bility of extending to them the services of a home visitation teacher. Dental Service: The Department extends two distinct dental serv- ices to the public, namely, dental health educational service in the elementary schools of the city once each year, and dental clinic service to the children of indigent and borderline families in three dental clinics operated by the Department. The dental health educational phase of the dental service consists of examination of teeth, sending home of defect notices and educational literature to the parents, follow-up of severe dental cases into the homes by the school nurses, and lectures to the chil- dren in the various grades of the school. The lecture work is arranged for the various grade levels and all of it is visualized with movies. The primary func- tion of the dental health educational program is to call attention of the parents to the condition of their children’s teeth, point out to the parents their re- sponsibility in the dental picture, and educate the children as to the value of good oral health. 24 The dental clinics operated by the Department serve eligible children under twelve years of age. These children receive the regular dental care con- sisting of oral prophylaxis, extraction of aching or badly decayed teeth, and filling of teeth which have cavities but can be restored to normal healthy form and function. Children over the age of twelve years receive emergency dental care only. This consists of stopping toothache by treatment, filling of the tooth, or extraction of the tooth. Oral prophylaxis is given to the children by the dental hygienists who spend two afternoons each week in the dental clinics. The eligibility of children for dental service is established by the school nurse when application is made for free dental care. Direct relief recipients are accepted upon proof of their established indi- gency by presenting relief cards to the nurses. Bor- derline cases are accepted for dental care only after the nurse has made out a social history, establishing the financial status of the family and determining eligibility. The dental clinics operated by the Department are: 1. Central Dental Clinic — Eighth Floor of City Hall. 2. Keenan Dental Clinic — Keenan Health Center, N. 36th St. and W. Auer Ave. 3. South Station Dental Clinic — S. 13th St. and W. Windlake Ave. 25 Teacher Examinations: Under the rules of the Board of School Directors, teachers are examined by the School Hygiene Divi- sion upon their entry into the service, when trans- ferred to the permanent list after three years of pro- bationary teaching, upon their request for leave of absence with pay due to personal illness, upon their return to service after such leave of absence and upon their request for retirement with pension, if this is based on ill health. The School Hygiene Division and the Welfare Department of Schools (formerly the Attendance De- partment) work in close cooperation. School absences in about eighty per cent of cases are caused by sick- ness. When the nature of the illness is not definitely known, these cases are referred to the nurse for in- vestigation. When the advisability of school attend- ance is in question, this is determined by the School Hygiene Division. This division also acts in an advisory capacity to the other departments of School Administration when questions involving health and physical welfare in schools are under consideration. The following clinics are available, and are used by the School Hygiene Division: 3 Full-time Operating Dental Clinics—Operated by School Hygiene Division. 2 Half-time Operating Dental Clinics—Operated by School Hygiene Division. 26 5 Oral Hygiene Clinics — Operated by School Hy- giene Division. Daily Clinics for diseases of the chest — T. B. Div. of Health Department. Immunization Clinics — Division of Communi- cable Diseases. 1 Venereal Clinic — Division of Venereal Disease. 1 Mental Clinic — Milwaukee County Guidance Clinic. County Dispensary and County Hospital. Out-Patient Departments of the various hospitals, notably of the Children’s Hospital and Mt. Sinai Hospital. Marquette Eye Dispensary. Various hospitals of the city. BUREAU OF INSPECTION The Bureau is divided into four divisions: Sani- tary, Food, Meat, and Milk. The personnel consists of one chief, four assistant chiefs, two sanitary ser- geants, twenty sanitary inspectors, sixteen meat in- spectors, four food inspectors, nine dairy inspectors, and four stenographers. The Bureau takes care of contagious and infec- tious diseases of animals that could affect man, such as rabies and glanders. Reports of individuals bitten by dogs are received and a veterinarian after exami- ning an offending dog quarantines the animal for a period of fourteen days. Reexamination of the dog is made on the fourteenth day and if in good health the animal is released. If a dog has rabies its head is brought to the Bureau of Laboratories after death to verify the diagnosis. 27 The Duties of the Sanitary Division: One of the most important duties of the sanitary inspectors is to investigate all citizens’ complaints, except those pertaining to food and milk. Handling complaints involves correcting nuisances such as odors, dust, smoke, industrial noise, and almost any gen- eral insanitary condition. The inspectors make periodic general inspections of all factories and places of employment, public, parochial and private schools, public buildings, swim- ming pools and hospitals. Dance halls and theaters are approved by this division before the annual license is issued. The inspectors enforce all of the provisions of the city ordinances, State Board of Health rules, and Industrial Commission orders that pertain to building sanitation, ventilation, lighting and general maintenance. A city ordinance requiring landlords to provide sufficient heat in living and working places, where such quarters are rented with heat, is enforced by the division. All apartment, tenement and rooming houses in the city are inspected at least annually. Inspectors enforce regulations requiring general cleanliness, ver- min control, and freedom from excessive crowding. The city’s 2,400 rooming houses must meet all of the department’s requirements before the annual license is granted. 28 The division cooperates with the building, plumb- ing and relief departments by reporting conditions outside of the jurisdiction of the Health Department. Routine inspections include plumbing surveys to lo- cate dangerous or insanitary plumbing. The division conducts examinations for, and issues licenses to, fumigators and exterminators. The inspec- tors enforce regulations requiring proper safeguards when licensed fumigators use dangerous fumigants. Advice is given to individuals and property owners on rat, bug and vermin control and extermination. During warm weather, periodic inspections are made of yards, alleys and streets. The inspectors re- quire proper storage of garbage and refuse, rat con- trol, and the elimination of other insanitary condi- tions. Licenses for persons doing homework are issued, following inspections made for the purpose of en- forcing a state law that prohibits sweat shop condi- ditions. Other duties include enforcing the peddler ordi- nance and requiring all peddlers to obtain a city license; enforcing the "No Spitting” ordinance; en- forcing the ordinances prohibiting smoking on street cars and buses, and requiring proper heating of such conveyances in cold weather. 29 The inspectors quarantine cases of contagious and infectious disease, and release all cases of minor diseases, such as whooping cough and measles, when notified by the Division of Communicable Diseases. The division provides relief drivers and attend- ants for ambulance duty at the Isolation Hospital, and provides inspectors for Saturday, Sunday and holiday contagious disease and other health depart- ment duties. The inspectors distribute and collect cultures and other supplies for the laboratory. Besides sanitary laws, sanitary inspectors are re- quired to enforce all city laws when no police officer is present. The Duties of the Meat and Food Inspectors are: To see that the public receives a good, wholesome supply of food. (The term "food,” as used herein, shall include the articles used for food and drink or condiment by man, whether simple, mixed or com- pound, and all articles used or intended for use as ingredients in the composition thereof or in the prep- aration thereof.) They make regular inspections of all places such as groceries, meat markets, delicatessen stores, candy and ice cream parlors, taverns, restau- rants, wholesale candy factories, soda water factories, bakeries, sausage factories, slaughter houses, commis- sion houses; in fact, all places where food is prepared or manufactured for human consumption, to see that 30 the food in process of manufacture or preparation for sale is securely protected from filth, flies, dust or other contamination, or other unclean, unhealthful or insanitary conditions. Meat inspectors examine all carcasses of beef, pork, veal, lamb and mutton at time of slaughter and, if free from disease, stamp them with a Health Depart- ment stamp, designating that they are free from dis- ease. If carcasses are diseased, they are retained and a final examination made by the deputy of the Meat Division. Wherever food is found unfit, it is con- demned by the inspectors, a receipt given to the pro- prietor and a record of same kept in the Division. When food is condemned, it is oiled or burned by the inspector who condemns it. All vendors of food must have a food license issued by this department or a class B license, which is O. K’d by this department and issued by the city clerk, or a restaurant license, which is O. K’d by this depart- ment and issued by the State Board of Health, or a bakery and confectioner’s license, issued by the State Dairy and Food Commissioner. All ice dealers are licensed each year, beginning December 1st, provid- ing their ice comes from a source that complies with the ordinance. The inspectors investigate all complaints relating to food and remedy conditions, if the complaints are verified. They also investigate all complaints regard- ing food poisoning and bring samples of food to the Bureau of Laboratories for further analysis. 31 They purchase samples of various foods to see whether they comply with the state and city food standards and branding requirements. The Duties of the Milk Inspectors are: To see that the public receives a clean, wholesome supply of milk, cream and other dairy products. To investigate farm conditions and see that cattle are healthy, clean and tuberculin tested. To see that barns, milk houses and yards are clean and well-drained and that all pails, cans and stirring rods are clean and not rusty or open-seamed. To supervise the hauling of milk to the city so that the milk is not contaminated by dust or dirt and that is is not unnecessarily delayed on the way to the milk plant. To see that all milk plants and equipment are kept in a clean and sanitary condition. To see that milk is properly pasteurized, bottled and capped. To pick up samples for laboratory analysis of butter fat content and bacteria count. To make sediment tests of the milk as shipped by the producer and to determine whether objec- tionable odors are present. To investigate all citizens’ complaints relating to milk and dairy products. To license all milk dealers and their vehicles and to license all spring water establishments that sell spring water and see that their plants and equipment are kept in a clean and sanitary condition. 32 BUREAU OF LABORATORIES The functions of the Bureau of Laboratories, in their broadest sense, fall within the following gen- eral classifications: Administrational, bacteriological, chemical, serological and investigational. More specifically the operations of the bureau may be distinctly and descriptively placed within one of the following groupings: 1. Bacteriological and serological diagnosis and control of contagious diseases. 2. Serological examination of blood and cerebro- spinal fluid for evidence of syphilis. 3. Food control and sanitation—health and eco- nomic food surveys. 4. Milk and cream chemical and sanitary con- trol— milk plant survey system. 5. Water sanitation — Examination of public drinking water supply, public, industrial plant and private springs and wells, boys’ and girls’ camps, and bottled water. 6. Sanitary surveys—bathing beaches, swimming pools, river pollution. 7. Food poisoning investigations — including remedial and educational measures. 8. Hospital clinical laboratory analyses. 9. Police Department co-operative crime detec- tion examinations — gunpowder hand molds, drunken driver tests, toxicological analyses, etc. 33 10. Miscellaneous operations — including analyses and reports for other departments of the Mu- nicipal, State and Federal governments and certain health agencies. 11. Preparation of many thousands of culture, blood, sputum and other standardized outfits for collection of specimens, principally for use of physicians and institutions. 12. Inspection of city gas supply. The personnel consists of the following: one director, one food and beverage chemist, one bacteri- ologist and serologist, one senior bacteriologist, one senior chemist, two junior bacteriologists, one junior chemist, one laboratory assistant, one technician, and two clerk stenographers. A total of 93,000 to 120,000 examinations and analyses of specimens and prod- ucts of a greatly varied nature are made annually. Bacteriological, chemical and serological exami- nations, analyses, and investigations are carried on for the Commissioner of Health, the various divi- sions, hospitals and bureaus of the Health Depart- ment, the public (when the issue is in the public in- terest), Police Department and other departments and bureaus of the municipal government. Among the Bureau’s primary responsibilities are those of aiding in the diagnosis and control of contagious 34 and infectious diseases such as diphtheria, tubercu- losis, typhoid fever, dysentery, scarlet fever, cerebro- spinal meningitis, gonorrhea, undulant fever, tulare- mia, Vincent’s angina, whooping cough, rabies, syph- ilis, and the parasitic diseases. Laboratory results are necessarily of very material importance in con- nection with the prevention, diagnosis, and control of the communicable diseases. Constant endeavor is made to extend the usefulness of the laboratories as new methods are developed or discovered whereby laboratory diagnosis will aid in early detection of contagious and infectious diseases. Especially is this true with regard to diseases whose mode of trans- ference was formerly unknown or where previously there had been no practical method of rendering laboratory assistance. Many thousands of laboratory outfits for the col- lection of throat, nasal, cough, blood, sputum, and other specimens are prepared for distribution to physicians, various divisions of the department and outside associations and agencies active in disease control work. Most of the articles of food which appear upon Milwaukee’s tables are chemically analyzed annually to establish the presence or absence of ingredients detrimental to health, to determine whether there is an economic loss due to substitutions of inferior in- gredients or the products are lacking in the legally specified amounts of their more valuable components 35 or the public is being defrauded by false claims and representations. Bacteriological and microscopic ex- aminations are also made to determine sanitary qual- ity. Minor violations are corrected through educa- tion, the more flagrant cases by proper court action. An idea may be gained of the importance of this work by the fact that it is estimated that in excess of $100,000,000 is annually paid by Milwaukeeans for their food supply. Upon request at the laboratories analysis will be made of any food product bought in the Milwaukee market which the purchaser believes to be adulter- ated or of an illegal quality and a report given to the complainant. Information will be gladly received which will enable the Health Department to make an investigation and obtain its own first hand infor- mation of such law violations. It is of the utmost importance that the city’s milk supply shall be of the very best sanitary and nutri- tive quality that it is possible to obtain. Frequent bacteriological examinations establish the sanitary quality and in conjunction with the phosphatase test, determine the effectiveness of pasteurization of milk and cream as sold to the public. Frequent exami- nations are also made of certified milk, the only type of unpasteurized milk now sold to the public. In addition a chemical milk plant survey system has been originated and developed for the control of these products from an adulteration standpoint. 36 By this means the quality of the milk received by the various distributors and of the product which they sell is continually known and the public is assured that the product reaches them in a form unaltered from that in which it leaves the herds. While the sanitary quality of these products is of the utmost importance it is also most necessary that there be no depreciation of the quality of an essen- tial food supply for which it is estimated the public pays annually in excess of $16,000,000. The services of the laboratories are particularly essential in connection with water supplies. Daily analyses are made to see that the public supply is of proper bacterial purity and efficiently chlorinated. In addition frequent sanitary examinations are made of all bottled waters sold in the city under license control by the department, and all public spring and well waters. The private water supply of any citizen will be examined without charge upon application of the owner or tenant when such source of supply is within the city. Examination of water supplies outside of the city should be arranged with the State Hygienic Laboratory at Madison. Sanitary surveys are made of public and semi- public swimming pools and bathing beaches, also of streams to determine sources and degree of pollu- tion of varying kinds. The gas supply for illuminating and heating purposes must comply with certain standards of heat- ing value, purity and pressure established by the Industrial Commission of Wisconsin. It is the duty of the laboratories to see that such standards are 37 observed, assuring a fuel of constant and depend- able heating value as free as possible of compounds which, by combustion, produce substances deleterious to health. Members of the laboratory staff furnish expert testimony in court in connection with the prosecu- tion of violators of food, drug, fraudulent advertis- ing, narcotic, liquor and other special and criminal laws. The number of such appearances in court varies materially each year. However, in a far greater number of cases laboratory certifications are accepted without the testimony of an analyst. A record file is maintained of thousands of pro- prietary and patented medicinal preparations which are more or less widely advertised. Such information will be gladly furnished to the public upon request. Any drug, the quality of which is established by law, which is purchased by a resident and in the Milwau- kee market will be analyzed without charge if the purchaser has reason to believe that the product is adulterated, contains a substitute or is below the standard of quality required. Investigations and researches are constantly being conducted of current health and other problems in the public interest. A system of recording, reporting and filing lab- oratory and other data is maintained in this depart- ment of its activities, and as in all others, an en- deavor is made to provide the best possible service to the other bureaus of the Health Department, the medical profession, the public, and agencies in the city actively engaged in health work. 38 CHILD WELFARE DIVISION The Child Welfare Division conducts well baby clinics throughout the city. There are 31 such clinics located principally in schools in the more heavily populated districts of the city. Here parents may bring well babies for hygienic advice, general health instruction, regular weighing and measuring, and for the administration of protective measures planned to conserve their health. Toxoid for the prevention of diphtheria, immunization against scarlet fever and whooping cough, as well as vaccination against small- pox are always available at these clinics, which are in charge of experienced and competent physicians, who specialize in the problems of infant welfare. In addition to the well baby clinics there are pre- school clinics, or clinics to which children between the ages of infancy and school age may be brought for regular physical examination. Cooperation with interested organizations such as the Parent Teacher Associations and the American Legion in the conduct of similar clinics aids materially in reaching a large number of children. At these clinics advice is given to parents concerning the correction of physical de- fects. These defects begin to occur early in life and are responsible for much of the physical deficiency in children entering school. 39 The Child Welfare Division cooperates with the day nurseries in the city, and regular visits are made to these institutions for the purpose of supervising the health of children boarded by the day. It also cooperates with the foster homes located in the city. These foster homes are licensed by the State Board of Public Welfare to accept and care for children in the absence of their parents. The Child Welfare Clinics of the department are located as follows: MONDAY — American Legion, 9:30 to 11:30 A. M., 1st and 3rd Mondays, 3418 W. Villard Ave. Lloyd St. School, 9:30 to 11:30 A. M., 2nd and 4th Mondays, N. 12th and W. Lloyd Sts. Hopkins St. School, 2:00 to 4:00 P. M., N. 15th and W. Hop- kins Sts. Garden Homes School, 2:00 to 4:00 P. M., W. Congress and N. Teutonia Ave. St. Hedwigs School, 2:00 to 4:00 P. M., E. Brady and N. Franklin Sts. Fernwood Ave. School, 2:00 to 4:00 P. M., 1st and 3rd Mon- days, S. Pennsylvania Ave. and E. Fernwood. Humboldt Park School, 2:00 to 4:00 P, M., 2nd and 4th Mon- days, S. Adams and E. Euclid Aves. TUESDAY—Longfellow School, 9:30 to 11:30 A. M., S. 21st and W. Mineral Sts. Margaret Allis House, 9:30 to 11:30 A. M., 2129 S. 6th St. Beulah Brinton Social Center, 2:00 to 4:00 P. M., S. Delaware and E. Porter Aves. Zion Lutheran School, 2:00 to 4:00 P. M., N. 21st St. and W. North Ave. WEDNESDAY — Victor L. Berger School, 9:30 to 11:30 A. M., N. 3rd and W. Ring Sts. 40 Forest Home Ave. School, 9:30 to 11:30 A. M., S. 15th St. and W. Forest Home Ave. Marquette University Medical School, 9:30 to 11:30 A. M., 545 N. 15th St. Wm. McKinley School, 9:30 to 11:30 A. M., N. 20th St. and W. McKinley Ave. St. James Church, 9:30 to 11:30 A. M., 2nd and 4th Wednes- day, N. 9th St. and W. Wisconsin Ave. Lapham Park Social Center, 2:00 to 4:00 P. M., N. 9th and W. Vine Sts. H. L. Palmer School, 2:00 to 4:00 P. M., N. Palmer and E. Brown Sts. Matthew Keenan Health Center, 2:00 to 4:00 P. M,, N. 36th St. and W. Auer Ave. THURSDAY—Merrill Playground, 9:30 to 11:30 A. M., N. 35th and W. Clybourn Sts. Burnham Field House, 9:30 to 11:30 A. M., S. 33rd and W. Burnham Sts. Goodwill Community House, 9:30 to 11:30 A. M., 901 S. 5 th St. Green Bay Ave. School, 2:00 to 4:00 P. M., N. Green Bay Ave. and W. Melvina St. N. 31st St. School, 2:00 to 4:00 P. M., N. 31st and W. Brown Sts. Luther Burbank School, 2:00 to 4:00 P. M., S. 60th and W. Adler Sts. N. Pierce St. School, 2:00 to 4:00 P. M., N. Pierce and E. Center Sts. FRIDAY — Parklawn Community House, 9:30 to 11:30 A. M. Oklahoma Ave. School, 9:30 to 11:30 A. M,, 1st and 3rd Fri- days, S, 10th St. and W. Oklahoma Ave. Doerfler School, 9:30 to 11:30 A. M., 2nd and 4th Fridays, S. 31st and W. Scott Sts. Cass St. School, 2:00 to 4:00 P. M., N. Cass and E. Kewau- nee Sts. South Side Health Center, 2:00 to 4:00 P. M., 1240 W. Wind- lake Ave. Matthew Keenan Health Center, 2:00 to 4:00 P. M., N. 36th St. and W. Auer Ave. 41 DIVISION OF NURSES The work of the Division of Nurses has been conducted on the community or generalized plan since 1918. This is defined as an "organized commu- nity service rendered by graduate nurses to the indi- vidual, the family, and the community. This service includes the interpretation of medical, sanitary and social procedures for the correction of defects, pre- vention of diseases and the promotion of health.” Advantages of the generalized nursing plan are as follows: Elimination of two or more nurses from the same agency serving the same family. Saving of nurses’ time through prevention of du- plicate interviewing, record keeping and travel. Elimination of contradictory planning for fam- ilies by different nurses within the same health agency or through multiple health agencies. Standardization of public health nursing proce- cedure in a single organization. Enables the nurse to do a well-rounded job in the guidance of the family or the individual in the attainment of healthful ways of living. The general duties of the public health nurse are as follows: Education of individuals and families so that they are better able to protect their own health. 42 Adjustment of family and social conditions that affect health. Correlation of health and social programs for the welfare of the family and community. Education of the community as to its need for developing and maintaining adequate public health facilities. Cooperation with all social, welfare and other health agencies. The staff of the Nursing Division includes the following personnel, administered under the direc- tion of the Commissioner of Health by the Superin- tendent of Nurses. Eighty-four field nurses operating from three sta- tions or Health Centers, each station under the super- vision of the district supervisor. Four special supervisors assisting and supervising the field nurses with problems affecting Child Wel- fare, Communicable Diseases, School Hygiene and Tuberculosis, in clinics, schools and home-call work, giving their entire time to their respective branches. An Instructor in Home Nursing conducts classes in Home Hygiene and Care of the Sick. This service is extended to lay and professional groups. A Nutrition Instructor extends consultation serv- ice to the Nurses Division. An Instructor in Public Health Nursing Education conducts an in-service educational program and an affiliate training course for post-graduate students. 43 The city is divided into three Health Center areas. Keenan Health Center, located at N. 36th St. and W. Auer Ave., houses the nurses and Health Center activities for the northwest portion of the city. The south side nurses have as their headquarters the first floor of the Johnston Emergency Hospital at 1240 W. Windlake Ave. and Health Center activi- ties for the south side are carried on there. Nurses serving the remaining area of the city re- port to the City Hall, Nursing Division. Each area is divided into districts of which there are 79, and each nurse is responsible for all of the activities in her own district. The size of the district is based upon the amount of work in that locality. Three nurses are assigned to the stations as assistants to the district supervisor; one drives the car for out- lying calls and one assists at the City Hall Tubercu- losis Clinic. Child Welfare: Babies registered in the City of Milwaukee are visited by the field nurses. At the time of the first visit a certificate of birth registration is delivered. Subsequent calls are made as often as the nurse deems necessary, depending upon environment and general health conditions. At least one visit per year is made on each child until he is immunized against diphtheria and smallpox. 44 The nurses demonstrate in the homes the prepa- ration of food, baby’s bath, bed and clothing. Any abnormalities or defects are noted and the mother referred to her private physician, or, if indigent, to a clinic for further advice. Baby boarding homes and day nurseries are vis- ited regularly by the field nurses. They also assist the doctors in the child welfare clinics, of which there are thirty-one. These clinics are conducted weekly in various parts of the city. Pre-School Clinic activities are carried on regu- larly in cooperation with the various Parent Teacher groups of the city. School Hygiene: Each nurse has from one to four public and paro- chial schools, depending upon the enrollment. Her schedule usually alternates with that of the school doctor. However, in high schools the nurse assists the doctor with physical examination of children and in the elementary grades with new entrant examina- tions. The nursing activities in the schools may be described under the following headings: Morning inspection of absentees or children sent by the teacher, routine inspection of rooms, prelimi- nary inspection after school has been closed for a week or more, and assisting in immunization clinics, chest clinics and with physical examinations. She 45 arranges, through the proper channels, for the trans- fer of children to the fresh air schools and to special classes for the mentally defective, the deaf, the blind, and those with defective speech. Most of the morning is given over to the school work; the home calls for absenteeism, physical de- fects, etc., are made in the afternoon. Tuberculosis: All cases of tuberculosis reported to the Health Department, where the physician in charge is will- ing, are visited in their homes and instruction given as to personal and home hygiene, frequent examina- tions of both patient and contacts are urged and arrangements are made for sanatorium care. The nurses also assist the doctors in the tuberculosis clinics and visit the fresh air classes regularly. Communicable Diseases: All cases under quarantine are visited by the dis- trict nurse. She modifies quarantine wherever pos- sible and gives general instructions regarding sani- tation and the proper isolation of the patient. In scarlet fever she issues a permit to the bread winner so that he may go to work from the quarantined home, provided he has no actual contact with the case in the home and does not come in contact with other children and is not a food handler. Diagnostic, 46 contact and release cultures are taken by the nurse and upon termination of the disease she releases the case providing she is satisfied that cleanup instruc- tions have been carried out. In her general round of duties she discovers many cases of contagious disease which have not been re- ported to the proper authorities. DIVISION OF TUBERCULOSIS Tuberculosis is a germ disease, caused by a micro- scopic organism, the tubercle bacillus. It is an infec- tious disease which spreads from one person to an- other by reason of close association. This accounts for the expression "tuberculosis is a disease of con- tact’* and for the axiom "every case of tuberculosis comes from another case.” Control and prevention of tuberculosis disease centers around individuals with active tuberculosis. The objectives of the Milwaukee Health Depart- ment’s Tuberculosis Division are: 1. To promote discovery, segregation, and treat- ment of all active cases. 2. To insure continued periodic and adequate examination of all contacts. 47 A. Diagnostic Stations: To assist in attaining this end, the Milwaukee Health Department has established four diagnostic stations, located as follows: 1. City Hall, 200 E. Wells St. — Room 803. Clinics are held here every Monday, Wednes- day and Friday morning from 9:00 to 11:00 and every afternoon from 1:00 to 4:00, except Sat- urday. There is also an evening clinic on Thurs- days from 6:30 to 8:00. 2. Keenan Health Center, 3200 N. 36th St. Clinics are held here every Tuesday morning from 9:00 to 11:00. 3. South Side Health Center, 1240 W. Windlake Ave. Clinics are held here every Monday, Wednes- day and Friday afternoon from 3:00 to 5:00 and every Thursday evening from 6:30 to 8:00. 4. Milwaukee Urban League, 904 W. Vine St. This clinic is held every Tuesday evening from 6:30 to 8:00 and has been established primarily for Milwaukee’s negro people. All Milwaukee residents are entitled to these diag- nostic facilities at any of the stations. Chest x-rays, when indicated, are available. Those individuals who are able to pay are charged a small fee for an x-ray. There is no discrimination made in the instance of non-ability to pay. Other diagnostic services (includ- ing chest examination, tuberculin tests, and sputum 48 examination) are free. The medical examining staff consists of one full time and four part time physi- cians. Treatment is not prescribed or given. All patients are returned to their referring physicians who receive a report of the examination. These re- ports include a tentative diagnosis and suggestions and recommendations for further observation and care. B. Laws Regarding Tuberculosis: The Wisconsin State Law on tuberculosis in Sec- tion 143.06 of the Wisconsin Statutes demands that all active cases of tuberculosis be reported to the local board of health. It also provides that an indi- vidual with active tuberculosis who fails to comply with rules to prevent the spread of the disease may be quarantined upon his premises or be committed by a court of record either to a tuberculosis sanato- rium or to some other place where reasonable care can be given, thus protecting children, if any, and other members of the household from becoming in- fected with tuberculosis. 49 C. Registering and Following of Reported Cases of Tuberculosis: When a case of tuberculosis is reported, a Health Department nurse visits the private physician to ob- tain his instruction with regard to the follow-up of the patient and his contacts, also asking the physi- cian’s permission for the nurse to call in the home. A period of care at Muirdale Sanatorium, Mil- waukee County’s hospital for the treatment of the tuberculous, is an immeasurable asset in the control of tuberculosis. When, for some reason, this cannot be accomplished and a patient with active tubercu- losis remains in the home, he is visited periodically by a nurse of the Health Department. She assists the patient and the family in carrying out precautions to prevent the infection of others. She helps to re- mind them of the necessity of careful examinations and x-rays by their own doctor or at a tuberculosis clinic if private medical care cannot be obtained. D. Fresh Air Classes: Milwaukee maintains eight "fresh air classes” for children who, although not ill, are physically below standard. These classes are located at the following schools: 1. Victor L. Berger 2. Luther Burbank 3. Cass Street 4. Clark Street 5. Eugene Field 6. Fourth Street 7. Oklahoma 8. South Girls* Jr. Trade 50 The choice of pupils is made by the Tuberculosis Division, and the schools are visited periodically by one of the division’s physicians. These schools pro- vide additional supervised rest, in some instances breakfast, and in every instance a well-balanced noon meal for the children in attendance. The food and transportation (where transportation is necessary) are provided free of charge by the Milwaukee Public Schools. E. Gaenslen Heart School: Children with heart disease whose activity must be restricted but whose physical condition does not demand complete bed rest may attend Gaenslen School. There are at present 65 children with heart disease who are daily transported by bus direct from home to Gaenslen School and back again at the school day’s end. Here a Tuberculosis Division phy- sician assists the teachers in outlining a program of activity for each child. Application for admission to the heart room at Gaenslen must be made to the Tuberculosis Division. Applicants are examined at the Diagnostic Station, Room 805 in the City Hall, previous to entering the Gaenslen heart room. The division physician who examines the children in the school also assumes the responsibility for their trans- fer back to regular school when their physical con- dition permits. 51 F. Tuberculosis Surveys: The Tuberculosis Division is continuously en- gaged in tuberculosis survey work. Here, the objec- tive is tuberculosis case finding in groups of appar- ently healthy children or adults. The procedure in- cludes tuberculin testing followed by x-rays of reac- tors. The number of active cases found in group studies is smaller than the number of active cases found in careful study of close contacts to patients with active tuberculosis. Every active case, however, leads to the discovery of others among the contacts. There is no tuberculosis survey project conducted by other tuberculosis agencies or by other divisions of the Milwaukee Health Department in which the Tu- berculosis Division does not play a part. The outstanding feature of all work done by the Tuberculosis Division is that it is education in the prevention, discovery, and control of tuberculosis. VITAL STATISTICS DIVISION The Vital Statistics Division is that part of the Health Department which is charged with the book- keeping of health. It receives, records and indexes in such a way that they will be easily and readily avail- able for persons having need of them, all marriage, birth and death certificates for the City of Milwaukee. Copies of these records are frequently necessary for legal or other purposes, and upon request certified copies of all these records are issued by the Division 52 of Vital Statistics. A fee of 50 cents is charged for this service. A birth record card is made out in this division for all children born in the city and a copy of this birth record is delivered to the home of each infant by the Nursing Division. The division also makes searches of the records upon request for the issuance of certificates of age to children who are seeking employment under the child labor art. All physicians and midwives practicing in the city are required to register at the office of Vital Statistics, and a record of such registration is kept. No body may be buried until a burial permit has been issued by this office nor may any body be disinterred for reburial without a disinterment permit. In addition to these functions the Division of Vital Statistics classifies all deaths according to cause, in accordance with the international list of causes of death which is used throughout the world, and com- piles many elaborate tables of births, deaths and marriages for the benefit of those needing informa- tion of this type. It makes a weekly report to the Commissioner of Health, to the State Board of Health and to the Census Bureau at Washington, and in addition sends regular reports to the newspapers and to the various cities. 53 DIVISION OF VENEREAL DISEASE The Venereal Disease Division was established by an act of the Common Council and opened January 13, 1920. The prime purpose and function of this division is the control of venereal diseases. The numerous activities may be summed up as follows: Examination of all persons applying for that serv- ice relative to venereal diseases. This consists of a general examination with reference to syphilis, dark field examination for the spirochaeta pallida (the germ of syphilis) and making the blood test, and the ex- amination of all urethral discharges for gonorrhea. Operation of a clinic for the treatment of emer- gency cases. Persons who are able to pay for their treatment are advised to consult their family physi- cian; if not, they are referred to the county dispen- sary or to the City Hall night clinic. Examination of all children brought in by the School Nurses in the Department of Child Hygiene. For treatment they are sent to the Children’s Hospital or County Dispensary, or referred to their private physicians. Examination of female transients of the Home for the Friendless for the detection of gonorrhea or syphilis. Voluntary examination of students and operators of beauty culture schools. 54 Examination of all vagrants brought in by the police department. Routine consists of an examina- tion for syphilis, a blood test, and examination for gonorrhea. Examination of delinquent girls brought in by the various social service agencies relative to venereal disease and pregnancy. The maintenance of the service where private physicians send patients for blood tests, smears for gonorrhea and dark field examinations, reporting re- sults of these examinations to the private physician. The maintenance of the service where individuals can obtain eugenic blood examinations. These reports are sent to the private physician designated by the patient. Co-operation with the State Board of Health and the United States Public Health Service in reporting and controlling venereal diseases. Maintenance of a daily clinic at the Health De- partment, City Hall, where these various functions are carried out. Operation and management of the night syphilis clinics for individuals unable to attend the ordinary day clinics. A clinic is conducted in the City Hall on Thursday evening and another at the Urban League on Tuesday evening. The latter clinic is operated for the special benefit of negroes. Lectures on sex education and venereal disease will gladly be given interested groups by the Instruc- tor in Social Hygiene of the Milwaukee Health De- partment. 55 THE JOHNSTON EMERGENCY HOSPITAL The Johnston Emergency Hospital is situated on the south side of the city, at the junction of South Thirteenth, West Windlake Avenue, and Grant Street. It gives treatment to emergency cases entering the hospital, these coming principally from the area south of the river. It is a first aid or receiving hos- pital, transferring its patients to other hospitals or home as soon as safe arrangements can be made. It cares for cases of sudden sickness on the street or in public places, accidents of all kinds—traffic, street, in- dustrial, those happening at home, on school grounds, or in public places. Its patients include sick and wounded prisoners, cases of delirum tremens, suicides, and acute illnesses, burns, frost bites, insect and ani- mal bites, emergency obstetrical cases, poisonings, lacerations, contusions and abrasions, fractures, cranial and intra-cranial injuries. The cases range from trivial accidents to the most serious — fractures are very numerous. An x-ray equipment renders possible their examination by this means, when necessary. A well equipped laboratory is also available. Young and old people found wan- dering on the street are cared for until properly placed. The staff consists of four (4) licensed physicians, Medical Director and a Consulting and Advisory staff, Superintendent, Assistant Superintendent, four (4) supervising nurses and eight (8) floor nurses. This is a twenty-four hour service to an ever-increasing number of patients. 56