PART II
DESCRIPTION OF PROBLEMS AND SERVICES

Vital Statistics.

The recording of births, marriages and deaths is one of the duties of the town clerk, who is the official registrar of the city. Birth certificates are checked for completeness and reconciled before filing. Certificates for each year are bound according to date and are indexed by name. Supplementary reports of names are received and recorded in the proper places in the birth certificates.

Tabulations are made by the clerk of the Board of Health of communicable disease cases reported to the health officer, and of all deaths by months and cause, in addition to detailed tabulations of infant deaths by cause, by sex and by months, and of all deaths by age and by months. These data are printed in the annual report. Graphic charts are not prepared.

Death certificates are checked before being filed, are indexed, bound and stored in a fireproof vault. There is no local checking and subsequent reconciliation of deaths against the reported cases of communicable diseases. The vital statistics report of the State Department of Health is the principal channel of tabulation and publication of death records.

Population.

As previously indicated, the 1930 population of Meriden was 38,481, the sex distribution showing a slight excess for the females (50.3%) over the males (49.77%). There is a slightly higher proportion of persons 10 to 20 years of age and those over 55 than for the State as a whole and for the United States, a factor which tends to raise the general mortality. The native white population of foreign or mixed parentage shows a predominance for persons of Polish and German groups, while the percentage of persons of Italian and Irish extraction is considerably less than in the rest of the country or State. The foreign born population is highly represented among the Polish, Italian and German, groups in the order mentioned.

Births.

The birth rate in Meriden in common with that for the country as a whole, has been steadily declining during the past 30 years. In the period 1926-30, the average number of births per 1,000 population was 17.1, while in 1930 the birth rate was 15.1.

Infant Mortality.

The mortality among infants has long been rightfully regarded as one of the most sensitive indices of the health of a community. For this reason it is gratifying to observe that Meriden's infant mortality rate (deaths under one year of age per 1,000 live births) has undergone a gradual and considerable decline. The average rate during 1881-1885, as shown in chart 1, was 155.4. In 1926-30, it was 61.1, and 55.1 for the year 1930. This improvement in infant survival has come notably within the past fifteen years, the rate has been over 100 but once since 1915, and that during the influenza year of 1918. Since 1920 the highest rate was 77.1 in 1926. The 1930 rate was the lowest recorded since adequate records have been kept, except for the year 1919.

For the year 1929, the statistical report of the American Child Health Association lists the infant mortality rates of 141 United States cities which had populations between 25,000 and 50,000. Meriden ranks 45th in this group, 31.2 per cent of these cities, having infant mortality rates less than, and 68.1 per cent having rates greater than hers.

An analysis of the infant mortality rate by particular causes of death reveals that much of the decline taking place within the past two decades is due to the reduction in mortality from diarrhea and enteritis.

Chart I. shows the decline in deaths under 2 years of age from this cause, which has been reflected in the decline of the infant mortality rate. On the other hand, infant deaths due to premature birth, congenital debility and other diseases of early infancy have not shown a concomitant decline, as the following figures show.

CHART I.

Deaths Under One Year Of Age Per 1,000 Live Births From Diseases of Early Infancy

In 1930, a total of 32 deaths occurred of infants born to resident mothers. The causes of death are as follows:

Congenital debility and malformations	24
Broncho pneumonia	13
Influenza	1
Bronchitis, acute	1
Diarrhea and enteritis	1
Erysipelas	1
Drowning	1
	32

Twenty-five of the infants dying were males and only 7 were females. Of the deaths from congenital debility and malformations, 19 were males and 5 females. Sixteen of the infants died in a hospital, 15 at home, and 1 homicidal drowning occurred in a brook in Meriden.

Twelve of the deaths occurred within 24 hours of birth, 8 during the first day, 2 after the first day but before 1 week of age, 3 from one week to one month of age, 2 from one to six months, and 5 over six months of age.

Three deaths of infants born to non-resident mothers were recorded in Meriden in 1930. The causes of deaths were: whooping cough at 9 months, atelectosis at 27 hours of age, and encephalitis lethargica at 10 months.

CHART II.

General Mortality.

Perhaps the most important facts revealed by a study of the mortality in Meriden over a period of fifty years are those shown in a tabulation of the ten principal causes of death. Table VI gives such a tabulation for the initial years of each decade since 1880, and shows the marked changes which have taken place with respect to predominating causes of mortality. Most important is the displacement of tuberculosis as the principal cause of death. In 1930 this disease had dropped from first to sixth place. Although the inclusion of deaths at the Undercliff Sanatorium from 1910 to 1927 kept the rate from this cause higher than it otherwise would have been, the decline as shown in Table VI is nevertheless real and significant. Diarrhea and enteritis under 2 years of age has disappeared as one of the 10 leading causes of death. Typhoid fever and diphtheria have fallen below tenth place. Pneumonia has persisted as one of the ten leading causes of death, with varying positions, but never lower than sixth place. Accidents have maintained an almost constant position in the list. Heart disease, the leading cause of death at present, has gradually risen to that position since 1900, closely followed by cancer, which did not appear among the ten principal causes until 1900. Cerebral hemorrhage and nephritis have also assumed new and commanding positions.

All of these observations clearly reveal the changing emphasis in health work. In place of the infectious diseases, the more baffling causes of death connected with human maturity and decay are now foremost and present problems of public health greatly differing in form and complexity from those of previous years.

TABLE VI.

Ten Principal Causes of Death, Meriden, in Censal Years from 1880 to 1930

Order	1930	1920	1910	1900	1890	1880
1	Heart disease	Tuberculosis	Tuberculosis	Tuberculosis	Tuberculosis	Tuberculosis
2	Cancer	Heart disease	Diarrhea and Ent. under 2	Pneumonia	Pneumonia	Convulsions
3	Pneumonia	Cerebral hemorrhage	Pneumonia	Apoplexy	Diarrhea and Ent. under 2	Cholera Infanturn
4	Cerebral hemorrhage	Influenza	Diseases of early infancy	Influenza	Diphtheria	Pneumonia
5	Nephritis	Cancer	Heart disease	Diarrhea & enteritis	Apoplexy	Diseases of early infancy
6	Tuberculosis	Pneumonia	Cancer	Heart disease	Accidents	Heart disease
7	Diseases of early infancy	Nephritis	Nephritis	Cancer	Bronchitis	Typhoid and typho-malaria
8	Accidents	Accidents	Cerebral hemorrhage	Nephritis	Diseases of early infancy	Meningitis
9	Suicide	Diseases of early infancy	Accidents	Accidents	Typhoid	Diphtheria
10	Influenza	Diarrhea and Ent. under 2	Whooping cough	Convulsions	Nephritis	Accidents

CHART III.

Meriden general or crude death rate from all causes has shown a marked decline. In 1881-1885, the average rate was 15.8, in 1926-1930 in chart 3 reached a low point in 1927 with a rate of 10.4. Since then it was 11.5 deaths for 1,000 population. This decline, shown graphically the death rate has risen slightly as follows: 1928, 11.4; 1929, 11.4; and 1930, 11.7. This increase is insignificant, but gives a strong hint that the decline in the death rate is slowing up and that little more in the nature of a further decrease is to be expected under present conditions of environment and health practice. Indeed, we may see the death rate rise slightly in future years as the falling birth rate reduces the percentage of the population falling in the younger age groups. Such reflections apply not merely to Meriden, but as well to other communities, to the state, the nation, and most of the civilized world.

Communicable Diseases.

The trend in mortality from communicable diseases in Meriden has shown a gradual decline. This is shown graphically in the case of typhoid and diphtheria in charts 4 and 5.

CHART IV.

But six deaths occurred from typhoid fever in the eleven years 1920-1930 inclusive, and none in the last four years. Comparable results cannot be shown, however, for efforts to eradicate diphtheria. But two of the above years from 1920 to 1930 are credited with no deaths from this disease, and in 1928, 4 deaths occurred, giving a rate per 100,000 population of 10.6. In 1930, 5 deaths were recorded, with a rate of 13.0. No deaths were reported for paratyphoid fever, smallpox, mumps, poliomyelitis, or German measles in the eleven year period.

One death in 1927 was recorded as due to malaria. Aside from diphtheria, tuberculosis and pneumonia, the communicable disease causing the greatest mortality is pertussis, or whooping cough. A total of 34 deaths were recorded for this disease during the eleven year period. The rate per 100,000 population has varied from 20.0 deaths in 1920 to none in 1927, 1929 and 1930. In 1928 there were 5 deaths from whooping cough, with a rate of 13.2. Measles in mortality has fluctuated somewhat during the period 1920-1930, the highest rate of 16.7 (6 deaths) being recorded for 1923, and the lowest, zero, for 1921, 1922, 1924, 1927, 1929, and 1930. No deaths occurred from scarlet fever during the years 1927 to 1930.

CHART V.

In the case of the respiratory diseases, the greatest toll of death was taken by lobar pneumonia. The number of deaths from this cause has varied between 34 in 1926 and 15 in 1923 and 1927. The specific death rate from lobar pneumonia in 1930 was 77.8, higher than that for 1920 which was 63.0, indicating the lack of decline in mortality from this disease. Deaths from broncho-pneumonia were not specifically reported as such until 1925, when 24 deaths from this cause were recorded, with a rate of 65.3. The rate in 1930 was 49.3 (19 deaths). Influenza has been credited with a number of deaths each year, the highest for the period 1920-1930 being in 1920, when 47 deaths from this cause occurred, with a specific death rate of 134.5 per 100,000. The nation-wide influenza epidemic of 1928-29 but slightly affected the mortality in Meriden during that period.

Tuberculosis.

The opening of the Undercliff sanatorium in 1910 caused the specific death rate, from tuberculosis in Meriden to rise and to indicate a mortality in the city from this cause of death much larger than it should have been (chart 6). This untoward effect was mitigated in 1918 when the sanatorium was restricted to children, and, of course, any effect the sanatorium had on Meriden's tuberculosis death rate was entirely removed after 1926 by the introduction in the State of the system of allocating deaths to place of residence. During the eleven-year period, 1920-30 inclusive, the rate of death from tuberculosis has shown a substantial decline. In 1920 the rate per 100,000 was 217.5, in 1930 it had fallen to 83.0. The low for this period was recorded in 1929 when only 26 deaths occurred, giving a rate of 68.0.

CHART VI.

Heart Disease.

In common with the rest of the country, Meriden has been affected by an increasing mortality from heart disease as shown in chart 7. The number of deaths per 100,000 from this cause was 58.5 during 1881-85 and rose to 88.7 in 1901-05 and to 172.8 in 1926-30. The rate in 1930 was 132.2.

Cancer.

The specific death rate from disease, has shown a steady rise within the past few decades. In 1881-1885 the death rate for cancer was 39.0; in 1901-05, 74.6; in 1921-25, 116.0; and for the period 1926-30, 125.2 deaths per 100,000 population. The rate for 1930 was 127.0. The trend of the mortality from this cause of death is shown in chart 8.

CHART VII.

CHART VIII.

The Puerperal State.

The mortality of mothers due to child birth is a perplexing problem in the United States. The specific death rate from this cause has remained practically constant in spite of efforts to reduce it. Meriden is no exception. For the eleven year period 1920-30, the average number of maternal deaths was 5.2 per 1,000 live births. The yearly rate during this period has fluctuated from 1.5 in 1927 to 9.1 in 1922. The rate for the year 1930 was 8.6.

Mortality in 1930.

In the year 1930, 444 deaths of Meriden residents were recorded, of which 406, or 91.4 percent took place in the city, and 38, or 8.6 per cent died out of town. Forty-two deaths of non-residents occurred in Meriden in 1930. Nearly two-thirds of the resident deaths in the city took place at home. The other third, 127, in actual numbers, occurred in a hospital or maternity home. Of the 38 resident deaths out of town, 5 occurred in a private home, and 33, or 85.8 per cent, in a hospital.

The age distribution of the resident and non-resident deaths is given in Table VII.

TABLE VII

Age Distribution of Deaths of Meriden Residents and of Non-Resident Deaths in Meriden

	Residents		Non-Residents
Age	Number	Percent	Number	Percent
Under 1 year	32	7.2	3	7.1
1 - 9 yrs.	16	3.6	4	9.5
10 -19	13	2.9	4	9.5
20 - 29	27	6.1	2	4.8
30 - 39	28	6.3	1	2.4
40 - 49	41	9.2	5	11.9
50 - 59	63	14.2	10	23.8
60 - 69	95	21.4	7	16.7
70 - 79	80	18.0	3	7.1
80 - 89	43	9.7	3	7.1
90 - 99	6	1.4	0	0
	444	100.0	42	99.9

Deaths under one year of age amounted to 7.2 per cent of the total resident deaths. Only 6.5 per cent of the residents dying in Meriden were between 1 and 20 years of age, 12.4 per cent were between 20 and 40 years, and 23.4 per cent between the ages of 40 and 60. The residents dying over the age of 60 accounted for 50.5 per cent of the total.

Communicable Disease Control.

Effective control of communicable diseases depends upon prompt reporting of cases to the health officer and subsequent study and follow up measures by medical and nursing personnel in the community. Reports of cases made to the local health officer are transmitted by him to the State Department of Health. Card files of case reports with a limited amount of supplementary data, including dates of placarding, home visiting, and release, are maintained.

TABLE VIII

Cases and Deaths from Communicable Diseases - Meriden

	Cases				Deaths				Avg. Cases per Death
	1928	1929	1930	Avg.	1928	1929	1930	Avg.
Typhoid fever	4	1	0	1.6	0	0	0	0	----
Diphtheria	18	8	69	31.7	4	0	5	3	10.6
Scarlet fever	47	87	229	121.0	0	0	0	0	----
Measles	492	114	46	217.3	1	0	0	0.3	724.3
Whooping cough	327	17	65	136.3	5	0	0	1.6	91.4

During 1930, there were 144 cases of German measles and 38 cases of chickenpox also reported. The above figures indicate reasonably satisfactory reporting on the basis of standards suggested by the American Public Health Assoc. However, a detailed study of case cards suggests that there are frequent instances of delay between the time of onset of certain of these communicable diseases and the time when a physician is first called. This suggests the need for education of the general public regarding the importance of these diseases and the desirability of securing early medical attention.

It is the general policy of the health department to have the nurse make at least two visits to homes where communicable diseases exist, one to institute quarantine and give instructions regarding the care of the patients and means of preventing spread of the disease, and a second visit for release from quarantine. It is gratifying to note that frequently, additional visits are made in behalf of cases of whooping cough. During an unusual prevalence of any of the communicable diseases, it is evidently impossible for one nurse to make as many visits to current cases of communicable diseases in the city as are suggested as desirable by the Appraisal Form of the Committee on Administrative Practice of the American Public Health Association. This rating schedule suggests that there should be made by professional personnel (physicians and nurses) 4 visits each per case of diphtheria, scarlet fever, typhoid, polio myelitis and cerebrospinal meningitis, and 2 visits each per case of measles and whooping cough.

Although case cards are available for making epidemiological case histories of the most important communicable diseases, because of the pressure of other duties these cards are only partially complete. Spot maps and chronological charts showing the prevalence of important diseases by weeks are not prepared, although they would be helpful for administrative purposes. General administrative control measures for communicable diseases conform to the State Sanitary Code and are in line with accepted practices. While the health officer is prepared to and does render consulting diagnostic service upon request, it is the usual practice to accept the physician's diagnosis on a case and not more than 10 consulting calls are made during the course of a year. Occasionally, an epidemiologist of the State Department of Health is requested to aid in making the diagnosis of obscure cases.

The Meriden hospital has an isolation unit of 5 beds for emergency purposes, but the facilities are not regularly used. Only one case of diphtheria besides 2 cases of cerebrospinal meningitis and 44 cases of tuberculosis were admitted during the fiscal year 1930-31. There were also 21 cases of lobar pneumonia, and 10 cases of broncho-pneumonia treated in the hospital last year. Communicable disease cases needing hospitalization are as a rule sent to the Hartford or New Haven hospitals, including cases developing in the Meriden hospital. For a city of the size of Meriden, with a general hospital as well operated as this one, it would seem desirable for practical and economic reasons to provide for more satisfactory local hospitalization of communicable disease cases in a wing which might be used for other general hospital purposes at periods when communicable diseases are not prevalent and when additional beds for general purposes would be a distinct asset to the community.

Laboratory Service.

Although the Meriden hospital laboratory is well equipped, and staffed, the work is confined primarily to hospital patients. General public health laboratory work is performed for the city in the State Department of Health laboratory in Hartford. While the service rendered is of a high quality, it would seem more practical and also desirable for a city of the size of Meriden to provide for most of its own public health laboratory work.

The facilities of the State laboratory provide for routine bacteriological and chemical analysis of water and milk; serological, diagnostic examinations for the typhoid group of fevers, syphilis, pneumonia typing, and undulent fever; cultural or microscopic tests for diphtheria, Vincent's Angina, septic sore throat, tuberculosis, gonorrhea, rabies, and other less commonly requested special examinations. Confirmation of an organism for its virulence by animal inoculation methods is also employed when needed.

Access to the records of the State laboratory was given by Mr. F.L. Mickle, Director. Examination of the files for the calendar year 1930 revealed that approximately 2,200 specimens of all kinds received from Meriden had been submitted to 6,000 to 7,000 analytical procedures. Hence a large volume of valuable diagnostic and control laboratory work is performed free for Meriden by the State Department of Health.

Venereal Disease Control.

There is a state law, requiring the reporting of cases of venereal diseases the health department. During 1930 there were only 19 cases of syphilis and 48 cases of gonorrhea reported. Unlike the other communicable diseases previously discussed, it is obvious that reporting of syphilis and gonorrhea is far from complete or satisfactory from a public health viewpoint. There is no organized clinic service and no followup work done. Anti-luetic treatment is given to clinic-type patients at the Meriden hospital, the patient coming by appointment to the accident room. The treatment is administered by a member of the house staff. Approximately 25 patients received treatment in a year. A small charge js made for patients who are able to pay, but for others, the service is free. These are diseases of enormous public health importance which require medical skill and epidemiological and social investigations for proper handling. There is an urgent need for developing more complete control services in the city, including an organized clinic as an outpatient service of the hospital, facilities for follow-up of delinquent treatment cases for positive educational activities, and for more comprehensive legal-protective measures.

Tuberculosis Control.

Tuberculosis is a communicable disease of particular importance to the public health because of its chronic character, because it usually affects family groups, and particularly children and young adults, and because it is one of the principal causes of death. The problem in a given community can be estimated on the basis of knowledge of the number of deaths of residents occurring annually for at least three years. It is customary to estimate that there should be 5 known cases under supervision for each annual death, on the average. With the present size of family, there are usually 3 contacts of each active case. It may, therefore, be figured that the tuberculosis problem in a community concerns roughly 21 people for each annual death, i. e., the fatal case, 5 active cases, and 15 contacts.

In Meriden during the 3 years 1928-1930, there was an average of 30 deaths per year. On the basis of accepted practices, there should have been at least 60 cases reported (2 cases per death on the average), but an average of only 44 cases were reported per year during this period. The problem may be roughly estimated as follows:

30 fatal cases

150 active cases

450 contacts, mostly children

630 total individuals concerned

The health department has no organized program of tuberculosis control and there is no director of the work. Case reports are received and filed and copies of reports are transmitted to the state department of health. The sanatoria report to the health department when cases are admitted or discharged. There is no register of tuberculosis cases, so fundamental in administering a co-ordinated tuberculosis control program in a community.

Practically all the work done in the community in this field is by one nurse of the Visiting Nurse Association, except for diagnostic service provided for a limited number of contact cases through the co-operation of Dr. Cole Gibson and his staff at Undercliff sanatorium. A few cases of tuberculosis (44 in 1930-31) are temporarily hospitalized at the Meriden hospital, but most of the cases needing institutional care are sent to the state sanatoria.

The Visiting Nurse Association carried 132 cases of tuberculosis during 1930, and made 1,551 visits to diagnosed cases, of which 709 visits were to post-sanatorium cases, besides 937 visits to 308 contacts. In total volume, this represents a large amount of field visiting for the number of known cases. However, from previously noted estimates of the problem, it is clear that there is considerable delay on the part of cases recall a physician early, and this fact is associated with incomplete reporting and in bringing early cases under care at a time when they would most benefit from medical and nursing supervision.

It is gratifying to note that some work is being done with contacts. Tuberculin tests are given by the nurse and the case is subsequently taken to Undercliff sanatorium where the results are read by a physician, a physical examination is made, and X-ray examinations are carried out when indicated, at the expense of the sanatorium. In 1931, tuberculin tests were given 53 contacts and 40 proved positive. There were 63 X-ray examinations made. In view of the excellent service provided at Undercliff, it would seem wise to continue and extend this tuberculosis clinic service at the sanatorium for Meriden cases, by the organization of a weekly clinic, but consideration should be given to the provision of special funds for payment for X-ray and tuberculin testing work. It would also seem essential to provide in the health department for a director of tuberculosis work, on a part-time basis in order that the problem may be visualized, in its entirety, on a community basis. Consideration of the possibility of appointing the medical director of Undercliff to this position is suggested. Besides the routine work, it is now considered desirable, if the tuberculosis rate is to be materially reduced, that the anti-tuberculosis program be extended to the school age group, and the opportunities of a constructive program along this line are far reaching.

During 1930 there were 25 cases of tuberculosis admitted to state sanatoria from Meriden. Two deaths of Meriden residents occurred in sanatoria among the 46 total patients in these institutions during the year. A total of 10,823 patient days were spent in state sanatoria by residents of the city, and there were 32 patients still in these institutions on September 10, 1931. Nine of the patients in sanatoria during the year were children at Undercliff.

The acquisition of the land in the foreground of the Undercliff Children's Sanatorium and the erection of a new fireproof 100 bed building has increased the usefulness and appearance of this modern institution A high grade medical and nursing staff is maintained. One of the important activities has been the establishment of a grammar school with six teachers, who carry 100 children through the ordinary eight grades.

Meriden needs a comprehensive program of tuberculosis control. There should be a record and filing system for the recording of social and clinical data on diagnosed cases and the contacts with them. Every diagnosed case should be carried in the active files until death or removal from the community. The tuberculosis register should contain the names of all cases known to the health department, classified by such categories as "actively under control of the health department", "under care of private physician", "in sanatorium", and the like, and distinguished between active, suspicious, and arrested cases. The approved classification list of the National Tuberculosis Association should prove helpful in this regard.

Every effort should be made to secure an examination of all members of a household as soon as possible after the discovery of a tuberculosis case. In all tuberculosis and prevention work, emphasis should be placed upon effecting a separation of tuberculous individuals and susceptible children. The private physicians should report every new case of tuberculosis coming under their care, whether or not the case is known to have been previously reported from other sources. This includes all forms of the disease, active and inactive. In most communities the education and supervision of cases under private medical care rests with the private physician if he so desires, in accordance with the State low and provisions of the Sanitary Code.

The specialized tuberculosis nurse versus the generalized public health nurse is a question to be decided in each community. Theoretically, the latter should prove more advantageous from all angles. Supervision by a nurse well prepared in tuberculosis is necessary with either plan.

 Increased attention should be given to preventorium care and supervision of selected children in special school rooms. The preventorium is a 24 hour day, year around school, designed primarily for the child with the childhood type of tuberculosis, but may include, besides contacts, the undernourished child who is a potential tuberculous patient if exposed to infection, and that group of children chronically below par physically and requiring more intensive care than can be obtained in a summer camp or open window classroom. Tuberculin reactions are helpful guides in the selection of cases, especially if followed by X-ray and physical examination of reactors. Rest is the basic element of treatment. The preventorium also serves as a way station for the child discharged from the sanatorium to adjust himself gradually to activity before going back to regular school and home life.

The so-called open window classroom is a room set apart in the school, to which either contacts or physically under par children, including convalescents, are admitted. The element of open windows and a greater abundance of fresh air than is common in most school rooms is only one phase of its purpose. As with the preventorium, rest is an important object. Diet, regulated exercise and supervised play also need attention. These classes should be carefully supervised by a competent medical person to insure the proper selection of children and their care while in the room. In other words, the open window classroom should receive that group of children who, with reasonable care over a few months, may be restored to fairly normal health, whereas the preventorium admits those requiring longer and more intensive care. As will be discussed in the school health section, there is opportunity for improvement of these facilities in Meriden.

The voluntary agencies, especially the local and state tuberculosis associations, have been responsible for much of the local anti-tuberculosis efforts. The Meriden anti-tuberculosis association has been active in the promotion of sanatorium care, the establishment of a tuberculosis nursing service, and in educational activities. The receipts from the sale of seals for use in 1931 amounted to $3,673 and the expenses to $939.39, including $482.52 sent to the State for the local quota. A member of the Public Health Association (V. N. A.) board carries on most of the administrative work connected with Christmas Seal Sales. There seems to be needed a larger special tuberculosis committee, as a sub-committee of the Association, to aid in this work. It might also be desirable, to separate the detailed financial accounting from the regular Visiting Nurse budget and merely enter on that budget the income from this source.

Maternity and Child Hygiene.

The modern conception of an adequate child hygiene program includes provision for pre-natal and obstetrical care, infant welfare, preschool and school hygiene. Activities in this field are developing rapidly and have achieved promising results. By the full use of medical services provided by private physicians, clinics and hospitals, and with the assistance of public health nursing organizations and other available resources, we may hope to lessen maternal mortality and stillbirths to increase the vitality of children born alive, to safeguard them through the most dangerous periods of their lives, to correct their disabling defects, to pass a larger proportion of them into schools in good condition, and to graduate them from the schools better able physically to carry on the business of living.

The various aspects of this problem will be discussed separately. The major portion of the work in maternity, infant and pre-school care is performed by the Visiting Nurse Association. The protection of the health of mothers and young children is perhaps the most important of all the public health functions of a community.

During 1930 there were 581 births to residents of Meriden, with 28 stillbirths. A study of the records indicates the desirability of more prompt and complete reporting of births. City health departments have attempted in many ways to stimulate prompt reporting of births, by educating the people as to the many values of a birth certificate - for school entrance, for foreign travel, for legal reasons such as in the matter of inheritance, and for business purposes, -- as well as issuing in several cities particularly attractive certificates which parents are eager to secure. In many cities, certificates of birth registration are delivered to parents by nurses as a matter of routine.

There were 32 infant deaths in 1930, giving an infant mortality rate of 55.1 per 1,000 live births. The maternal mortality rate of 8.6 per 1000 births is higher than the average of 5.2 for the 11 year period 1920-30. Forty-seven per cent of the births occurred in hospital and 9.8 per cent were attended by midwives. In addition, 123 births to non-residents occurred in Meriden during the twelve months ending August 14, 1931,122 occurring in hospitals. There were 26 births to Meriden residents which occurred out of town, all but 3 in hospitals.

Organized home nursing service at time of delivery, to aid the attending physician in the home, is provided on a rotating basis by the staff of the Visiting Nurse Association, and the service was rendered in 100 homes in 1930. A fair percentage of the mothers so attended were registered at least 3 months before delivery with the nursing service. This service is more highly developed than in the average city and has proven its value to the community.

One large private home receives maternity patients, as well as convalescent and chronic cases and aged people. From March, 1931, to November 10, 9 maternity cases were received, 99 days of care having been given. It is questioned if this home is adapted at present, in terms of personnel and equipment to care adequately for maternity cases.

Midwives are registered with the State Department of Health Bureau of Child Hygiene, which gives field supervision of methods and practice.

During 1930, 108 mothers were registered for pre-natal care with the Visiting Nurse Association at least 3 months before delivery and 161 others were registered at varying periods of from one week to 3 months. A pre-natal clinic was opened at the hospital in August, 1930, and 35 patients made 113 visits to this clinic during the following 12 months, 27 clinic sessions having been held.

Field nursing supervision was given to 269 cases, a total of 902 visits having been made. A fairly large percentage of the pre-natal patients (27 on November 25) carried by the nurses as insurance cases. Postpartum care is also given to registered cases delivered by physician, and arrangements have been made to follow more closely than heretofore those delivered by midwives. It is the routine practice to visit the home daily during the first 8 days, and thereafter once a week for 6 weeks.

The Visiting Nurse Association conducts two baby health stations, with a volunteer physician in attendance for an hour weekly at the conferences held at headquarters. Only selected cases are seen by the physician. The second conference has been operative for only half of the year 1931. Attendance at 62 sessions during the year by 319 infants amounted to 1,658 visits. This is a reasonable number of visits in proportion to the number of infants registered, but the service should be materially strengthened by having a physician in attendance on a paid basis throughout each session. Furthermore, there seems to be an opportunity to extend this conference service to South Meriden.

A system of infant and child health stations is essential for the medical examination and hygienic supervision of infants and children not under care of a private physician. The mother or other person responsible for the infant's care should have access to a physician upon whom she may call for medical attention and advice. This extension of this service on a paid basis is one of the important needs in Meriden's child health program.

There were 4,945 home visits by nurses of the Visiting Nurse Association to 962 infants and 50 visits to 19 infants by health department nurses during the year ending October 1, 1931.

Baby boarding homes are licensed by the State Bureau of Child Welfare and are inspected once a year by a visitor from the Bureau. Records from the State bureau indicate that there are 6 licensed homes in the city; one licensed for one child, four for four children, and one for three children. In December, 1931, there were 3 children under one year of age and four children between the ages of 3 and 5 in these homes.

The estimated pre-school population is 3,062. During the fiscal year 1930-31, there were 142 children in these age groups registered at pre-school conferences, which are the same as those attended by infants. A total of 433 visits were made. It is considered good practice if 30 per cent of the pre-school children of a community are registered at clinics and make an average of 4 visits per child during the year. While the ratio of visits per child registered in Meriden is about four-fifths of the desirable goal, it is apparent that less than 5 per cent of the children of this age group are under conference supervision.

The nursing service rendered in the home in behalf of pre-school children reached 952 children (or 31 per cent for the Visiting Nurse Association) during the year, although the number of visits, 3,440 is somewhat less than the desirable quota of 4 visits per child on the average. During the same period, the health department nurses made 650 communicable disease control visits in behalf of 215 pre-school children and 50 visits to 19 infants under one year of age.

In another phase of pre-school work, the pre-school program in Meriden falls short, namely in the lack of service for making physical examinations of children about to enter school. It is considered good practice if 20 per cent of entering school children in a community are given such an examination within 4 months of such entering (at a rate of not more than 8 children per hour), and if the findings are made available for inclusion in the school records. In many cities and towns the Parent-Teacher Associations and the Women's Clubs co-operating with the State Department of Health, are taking an active part in furthering such a program. Furthermore, increased stimulus should be given to the importance of educating parents to secure immunization against diphtheria of their pre-school age children. An average of only a little over 300 pre-school and kindergarten children received this protective measure in each of the years 1930 and 1931.

Meriden Day Nursery.

The Meriden Day Nursery is located in the Y. W. C. A. and is open for pre-school and school age children. The only requirement for admission is that the mother work away from home during the day. It is believed desirable that the standards of the National Association of Day Nurseries, regarding admission, physical examination, immunization, adequate housing, care of food, especially milk, and daily program be adopted.

School Health Supervision.

School health supervision has become recognized as an important part of the school and public health program. There are fundamental reasons why a city or state should accept the responsibility for the conservation of the health of the children in its public schools. Children required to attend school must be protected against neglect, ignorance, or indifference of parents of some children who attend school while in the communicable stages of disease. When a community makes education compulsory, it must assume the responsibility for providing a healthful environment for the children. It is important to educate the child in the principles of healthful living so that he may himself have sound health and thus safeguard the community in the future. Furthermore, it is essential to find out and endeavor to have corrected physical and mental defects in the child before they affect his ability to learn and interfere with his school career. From the standpoint of economy, education, and hygiene, it is believed that every effort should be exercised to create health conditions which give every child a fair chance and enable him to get the most out of the years he must spend at school.

Purposes.

The primary purposes of school health supervision are five-fold. They are (a) to detect and prevent the spread of communicable disease; (b) to insure sanitary conditions at the school plant; (c) to discover early and guide the child to appropriate care for correction of physical and mental defects; (d) to promote sound physical development; and (e) to educate the child in the matters of community and personal hygiene and in the principles of healthy living.

The responsibility for school health work in Meriden is divided between the Board of Education, which conducts the work in the 17 public schools, and the Board of Health, which conducts the work in the 6 parochial schools of the city. During the school year 1930-31, there were 6,148 pupils in the public schools, including 426 in kindergarten, 996 in Senior High School, and 37 in a special school. There were 2,039 pupils in parochial schools.

The personnel provided for this work was as follows:

	Board of Education	Board of Health
Physicians, part time	3	1
Nurses, full time	3	1
Dental hygienist	1	0

In the public schools there were 2,049 pupils per nurse as compared with 2,039 pupils per nurse in the parochial schools. This is about the ratio recommended as desirable for effective service. The physicians serve on a part-time basis. There is no dentist, and the dental hygiene work was discontinued in 1931 because of lack of funds. Health education work is conducted largely by classroom and special teachers, but co-operation is also received from the Connecticut Dairy and Food Council.

Morning inspection of pupils for suspicious signs of departure from normal is routine practice for classroom teachers in elementary schools. It is the policy for nurses to spend some time each week inspecting pupils and to inspect certain grades at least every two months for the detection of minor skin, scalp and eye infections. Such inspection at least twice a year is considered desirable for all elementary schools.

All school buildings are said to be provided with approved sanitary drinking fountains or individual drinking cups, adequate lavatory facilities, individual towels and bar soap. It should be stated that many of the classrooms are crowded.

In the public schools, it is the policy to examine all children in grades 1, 4, 7, and 10, while in the parochial schools, children in grades 1 and 4, and children admitted to the school for the first time are examined. Parents are invited to be present at these physical examinations and several avail themselves of the opportunity. For example, in one week in December, 1931, there were 234 examinations with 61 parents in attendance.

Records of physical examinations made, of the defects found, and of the children brought to professional attention, are not systematically maintained and analyzed in accordance with the best practices, and for this reason it is difficult to estimate the success of this phase of the program.

During the last school year, there were 4,546 pupils examined and the results were reported to parents. Certificates of work completed by dentists were obtained for 747 pupils, while 348 pupils were passed as satisfactory. The teeth of 651 elementary school pupils were cleaned. The number of children examined and referred to parents represents a large amount of work, but the number known to have received attention considerably below what might be expected in a school population is considerably below what might be expected in a school population of this size. The health department made, during the year, 1,106 home visits and the Visiting Nurse Association 1,442 home visits on behalf of school children.

Health education is carried on by the teachers in conjunction with the regular school curriculum, and text books are used in grades 3-6 inclusive. It is the policy for teachers to weigh the elementary school children every two months and for nurses to carry out this procedure once a year. Notifications of weight are not sent to parents with the scholastic reports. In connection with the survey, an examination was given to sophomores in the high school to obtain some impression of the results of health education work in schools. The answers compared favorably with the results of similar tests in two other Connecticut cities where considerable attention is also given to health education in schools.

However, school medical services may be primarily administered in a community, a joint conference committee on school health, with representation from both the department of education and the department of health, will prove of value. The mutual assistance derived from such a committee through joint program planning and discussion of problems has been strikingly demonstrated in several communities.

An important function of school health supervision is the health examination of children for the discovery of physical defects. If this can be done by the family's attending physician and essential facts transmitted to the school, so much the better; otherwise these examinations, sufficiently complete to include vision, hearing, throat, heart, lungs, cervical glands and nutrition, should be made by school physicians assisted by nurses. The American Public Health Association has prepared school health record forms which would prove useful to the health staff as well as to principals and to the Superintendent of Schools and their use would aid in systematizing record keeping.

It is considered desirable that one examination be made at entrance and at least one thereafter (preferably two if medical personnel is adequate) with children's outer clothing removed to the waist and shoes and stockings off. Parents should be urged to be present, at least for the first examination, in order to enlist their interest in and understanding of the findings. At least 5 minutes per child, on an average, should be allowed for the group of examinations indicated. For many children, 15 minutes or longer is necessary. The second examination may occur in the fifth or sixth grade, while if possible, a third examination should be made in the eighth or ninth grade.

Provision should also be made for the examination of selected children by the principal for special reasons, as those failing in grade, new pupils admitted to the school system from other communities, and of cases suspected by the nurse, through her inspections, to need such examinations. In the high school, provision should be made for the careful examination of pupils who are to engage in competitive athletics. Examination should be urged when the child leaves the school system at whatever grade. There should also be some systematic plan to insure that teachers receive periodic health examinations and are known to be healthy before acceptance as teachers. The dental hygiene program should be renewed, with emphasis on the education of parents regarding the importance of securing the correction of defects by private dentists, and the relation of nutrition to the problem.

If children have not acquired a respect for health when they leave school, the health education program has failed in its main purpose. The school physician is in a strategic position to develop this respect for health and for the special ability of the medical practitioner as an aid in preserving health. So far as possible, children found to have handicapping defects should be referred to their private physician or dentist for attention. Records of pupils who receive professional attention should be maintained with a classification of the types of conditions treated.

In school health service, the nurse works with the teacher, physician and parents for the health of the child and is a connecting link between the community health resources and the home. The nurse should participate in the promotion of hygiene and sanitation of the school plant, assist in securing proper instruction of pupils and parents in the principles of healthy living, and assure herself that adequate nursing care is provided to sick children in their homes when necessary. The nurse-parent-teacher conferences in school are valuable as they familiarize the parent with the health program and environment in school.

Careful records concerning each child's physical condition, including the results of examinations and corrections made, should be kept on file in the school office. In some school systems, it has been found desirable to have the records of pupils of each classroom kept on the teacher's desk. It should be emphasized that a uniform terminology for defects and a standardized method for checking and recording corrections should be employed.

Physical Education and Recreation

Systematic physical education is regarded as a health promoting activity and should be included in a balanced program of health supervision under a qualified physical director in the department of education. This work seems to be effectively organized in Meriden. There is a full-time physical director in charge of recreation and physical training in the public schools. In addition, each junior and Senior High School has a full-time man and woman in charge of this work. In one of the large elementary schools, one teacher gives all of her time to physical training and hygiene instruction. In two others, the major time of a teacher in each school is given to physical training. Five elementary schools seem to have adequate playground area. While the Senior High School has no playground, the city has purchased a two-acre lot across the street for this purpose.

During 8 weeks of summer, one supervisor and 14 teachers are employed by the Board of Recreation to direct organized play and supervise swimming. This is an important provision. Other recreational activities will be subsequently described in the sections dealing with the several non-official educational and recreational organizations. The value of a year-round recreation system has become firmly established in the United States. The National Recreation Association has published a dozen reasons why a year-round recreation program is necessary. Many cities are conducting such programs successfully with large dividends in terms of human values. Over 300 cities are conducting recreation programs in charge of workers employed the year round. The impulse to play is universal, and recreation is essential to the life and growth of the child, as well as to the well-being of the adult.

The highest type of leadership is attracted to this work which continues and reinforces the school program. The purpose in training children and young people in the right use of leisure ought not to be merely fill up the idle hours, but also to create an active, energetic, happy citizenship. Not the least of the benefits is the reduction in juvenile delinquency when supervised play is established. A study made by Allen Burns in a large city showed marked reductions in juvenile delinquents among groups coming from the vicinity of the small playgrounds conducted by a special city commission in comparison with the city as a whole. Authorities state that the average cost of maintaining one juvenile delinquent in a reformatory for one year can provide a year's municipal recreation for scores of children.

Meriden has many organizations of a recreation and character-building nature which are a distinct asset to the community. Several of these organizations feature positive health to a limited extent, while others are contemplating increased emphasis on activities which stimulate the formation of proper health habits and interest in health education. The programs of the Boys' Club, the Boy Scouts, the Girl Scouts, the Y.M.C.A., the Insilco Club, the Red Cross, the Council of Catholic Women, the Woman's Club, and the Service Clubs are noteworthy for the interest shown in recreation and health, while the Charity Club, the Y. W. C. A., the Salvation Army, the Community Fund, the Community Welfare Association, and the churches among other organizations, have aided in many community problems relating to social welfare.

The Meriden Open Air Classes.

Open air classes are held in the Clara Barton School on Willow Street, in the same building which houses the ungraded special classes for mentally retarded children. The school is an old three-story brick structure divided vertically, one side being used by the open air classes and the other for the special classes. The basement and small playground surrounding the school are used jointly by both groups. Open air classes have been held in Meriden for 14 years, but in the present building for but 3 years.

Children are referred to the school by the school nurse, physician or teachers from all over the city, but final decision is passed by the school physician before a child is admitted. The open air classrooms accommodate 50 pupils, ranging in age from 5 to 16 years, but at the present time only 39 are in attendance. The small enrollment is partly accounted for not because of the lack of children needing this care, but because the school is not centrally located and because of its proximity to the classes for mentally retarded children.

A health and growth record, in addition to a complete story of physical condition, is kept for each child. In addition to frequent visits to the school by the school physician and nurse, the nurse also visits the homes when occasion demands. Eye tests are made by the school principal, defects recorded and the school nurse notified. As in the other schools, the Charity Club aids in the provision of glasses for those children whose parents are unable financially to purchase them. Talks on health habits and personal hygiene are given by the teachers during the morning inspection period.

There is need for washing facilities for the children on the first floor, more health posters and health education work, ventilation precautions, better lighting and improved sanitation in the basement rooms, and hot water on the second floor. The problem of lessening the danger from the fire escape might also be considered. Selection of children should be along lines suggested in the tuberculosis control chapter. A different school building should be used for mentally retarded children.

Senior High School Cafeteria and Lunch Counter.

The cafeteria and lunch counter are located in the basement of the high school and occupy what was originally a hallway, with a medium size room adjoining, now used as the kitchen. Food is dispensed at the 11:15 recess period over glass counters in front of which file an average of 750 of the total 1,150 pupils enrolled in the school. Three kinds of sandwiches (unwrapped), fruit, potato chips, candy, milk and chocolated milk comprise the usual recess lunch. In order to encourage the children to drink more milkit is served with cookies for the small sum of five cents. Children are taught what constitutes a well balanced diet by means of posters, classroom talks - especially in connection with gymnasium work - and the domestic science groups.

At 1:05 a cafeteria luncheon is served to teachers and to pupils who remain for the afternoon session. There is no special room for this purpose, but the pupils take their trays to the various classrooms, and the teachers, to a small dining room near the domestic science classroom.

Connecticut Dairy and Food Council Co-operation.

The Connecticut Dairy Council is the health agency of the dairy industry organized for the purpose of disseminating information regarding the proper place of milk and its products in the diet. The program, based on the eight health habits which have been set up by the American Child Health Association, is two-fold, a school and an adult program. In Meriden, little adult work has been done.

The school program which supplements that of the local schools consists of a series of health talks which are given in both public and parochial schools, in grades one to six inclusive. These stories are used for the primary, intermediate, and the upper grade children. They are illustrated with lantern slides when electricity is available, as well as means for darkening the rooms, and when such is not the case, property stories are given. These stories are written with the approval of educational as well as health authorities and are planned to supplement the school health program. These talks are given in auditoriums when available. However, many of the school buildings in Meriden are old and few have auditoriums, in which cases the stories are given in the classrooms.

Last year the Council obtained a small puppet theatre suitable for classroom use, and the "Scarecrow", a puppet show emphasizing the importance of right health habits, was given to the children in the public schools in grades four to six. The Council provides follow-up material for all of the stories which are used in the schools. Leaflets on the subject of food were distributed to the children following the puppet show. Other leaflets, posters, and projects are supplied the teachers. Aside from these, the Council sends out special leaflets four times during the year, at Thanksgiving, Christmas, St. Valentine's Day, and Child Health Day. Book covers (15,000) were supplied the Meriden schools last year carrying the eight health rules.

Adult Education Survey

Meriden was selected as a demonstration city for an adult education survey by the Carnegie Institute, which appropriated money for the enterprise. The study was conducted under the auspices of the American Adult Education Association which authorized the Meriden Y. M. C. A. to carry on the work. Fifty different classified groups were studied, and a full report is to be published in four sections. A preliminary report of the first thirteen groups studied has already appeared in mimeograph form.

As one of the results of this survey, a series of lectures on psychology is being given, at a total cost per person enrolled of $1.00. There is an enrollment of 255 individuals for these lectures. Two other courses have already been given, with an average enrollment of 200. It is noteworthy that one of the most frequently asked questions of individuals and groups was "how can we keep healthy?"

Public Health Nursing.

Public health nursing is defined by the National Organization for Public Health Nursing as an organized community service, rendered by graduate nurses to the individual, family, and community. This service includes the interpretation and application of medical, sanitary, and social procedures for the correction of defects, prevention of disease, and the promotion of health, and may include skilled care of the sick in their homes. One of the valuable measures of the program of modern public health work in a given community is the extent to which public health nursing service has been developed.

Community Nursing Service.

There are 14 public health nurses in Meriden distributed by agencies as follows:

Board of Health	2
Board of Education	3
Visiting Nurse Association	9

The combined nursing staffs give a ratio of one nurse to 2,750 population. To meet the ratio generally accepted as necessary for reasonably adequate service -- 1 nurse to 2,000 population -- 5 additional nurses are needed for the present population. Inasmuch as it has been previous in the school hygiene section, that the school nursing staffs are to meet the local problem, and inasmuch as one nurse should be sufficient for handling the major communicable disease problems, exclusive of tuberculosis, from the health department standpoint, it is clear that the shortage of nurses relates primarily to general field nurses. The only director or supervisor of nurses is in the Visiting Nurse Association. Although the three groups of nurses work separately, it is gratifying to note that periodic conferences are held for the discussion of problem mutual interest.

The outstanding features of a public health nursing program are as follows:

1. Home visitation of cases of acute communicable disease is carried out for the purpose of acquiring information of epidemiological importance, for the instruction of attendants in the technique of isolation, concurrent infection, and medical asepsis, for the taking of cultures and preliminary inspection of contacts, and for the dissemination of knowledge in regard to the value of vaccine and serum therapy. This work is the primary responsibility of the health department nurse. It has been the policy of the Visiting Nurse Association not to give home nursing care or supervision to communicable disease cases. In view of the experience and practice of many visiting nurse associations to visit communicable disease families and render necessary service in connection with their regular work, it seems desirable to consider a change in the above local policy in order that service may be continued in families already under care on a generalized basis. If the nurses follow out modern technique, as all nurses should, there is no practical danger in carrying out this procedure. In such instances, the health department nurse need only make two visits, one for instituting a quarantine and giving instructions which would later be supplemented by the Visiting Nurse, and one for release from quarantine. In fact, were there an adequate sanitary inspection service, the release from quarantine might be handled by the inspection except in cases where release cultures where release cultures were necessary. There is an opportunity for all nurses to participate more actively in the dissemination of knowledge in regard to the value of vaccine and serum therapy.

2. Assistance rendered to physicians at tuberculosis clinics is an important function of nurses in communities where such clinics are conducted. In Meriden this type of service is skillfully rendered on a limited scale at the Undercliff Sanatorium, but the nurse of the Visiting Nurse Association in charge of this work is obliged to transport patients more extensively than is considered desirable from the standpoint of most effective use of a nurse's time. Coupled with this work is the visitation in their homes of cases of tuberculosis, of contacts, and of post-sanatorium or arrested cases, for bringing contacts and suspicious cases to medical attention and for instruction of patients and families. There are more open cases than is desirable in homes with childhood contacts. It is also questioned if sufficient opportunity is taken for instruction of patients and contacts regarding measures for preventing exposure and other important factors related to control of this disease.

3. In many communities, assistance is given to physicians at venereal disease clinics visitation in their homes of cases needing follow up or advice, and stimulating other members of the family to come to clinic. There is practically no nursing service rendered in Meriden in behalf of these types of cases.

4. Assistance is rendered to physicians in the pre-natal clinic by nurses of both the hospital and the Visiting Nurse Association, and the latter agency provides service at time of delivery for home cases attended by a physician. The Visiting Nurses serve the baby health stations and visit in homes in behalf of mothers and infants to give instruction to mothers and prospective mothers in the hygiene of maternity and infancy. This is an extensive service, but it is our impression that opportunities of giving instruction and of distributing valuable literature of the State Department of Health, of the U. S. Children's Bureau and other organizations at strategic times in the homes and in clinics are not fully utilized.

5. Assistance is given to the physician at the health station in the examination of pre-school children, as well as infants, but one of these stations is entirely a nursing conference with no medical attendant, while the central conference is largely of this nature, as the physician sees only very few selected children. Relatively little supervision is given children in boarding homes. The nurses visit in private homes to aid in securing needed treatments and to instruct mothers in the hygiene of childhood and the importance of proper habit formation, although the last item seems to be only partially stressed.

6. Assistance is given to school physicians by the school nurses in the examination and supervision of school children. A limited amount of home visitation is carried on to parents in securing needed treatments and to instruct mothers and children in the hygiene of childhood. Increased efforts to develop parent-teacher-nurse conferences in schools would doubtless facilitate this work, especially if more parents could be encouraged to be present at the time of the first examination of their children in school.

7. Instruction is given by the visiting nurses who work largely on a generalized basis (except for tuberculosis) in the technique of bedside generalized care, and they give such care when necessary in accordance with the medical instructions of the attending physician.

8. The Visiting Nurse Association also assists physicians to a limited extent in rendering adult health supervision, and co-operates with one of the large industrial concerns in giving service in homes to employees and their families.

Public health nursing may be administered by official or non-official agencies, or may be administered jointly. The difficulty of selecting any single plan to fit all conditions is apparent. At the same time, it has become realized that co-ordination of activities is essential for economy to suggest and effectiveness of service. It seems practicable to suggest consideration of the development of a joint committee of representation from each agency to study the possibility of co-ordinating the nursing activities.

The need for maintenance of adequate nursing standards and uniform procedures should be stressed. Even in many cities where the provision of bedside nursing has remained a function of voluntary agencies, there has been manifested a growing movement for the development of joint programs in which both public and private agencies unite. Nursing has long since ceased to be considered as a "charity"; it is regarded as a community activity conducting services available for all groups, whose support comes from the community, either through taxes, payment by patients, or by such contracting parties as insurance companies and individuals or community industries, or through contributions from chests. Public health nursing is necessarily a co-operative undertaking conducted in close relationship to the medical profession, social workers, teachers, hospitals, and other institutions. It is gratifying to note that the nursing service of the Visiting Nurse Association has become generalized, except for tuberculosis, and it would seem desirable, as soon as personnel and other factors may make it possible, that this entire program be so organized. Such a plan insures economy of the nurses' time involved in covering a small district, and provides a superior personal contact by a nurse who really knows, and is intimately known by the families with whom she works. Furthermore, it appears that a public health nursing service which combines the care of the sick on a visiting basis with the teaching of hygiene is far more effective as an educational force than a service devoted to education alone, because of the increased influence acquired by the nurse who actually renders service in time of suffering.

The keeping of accurate records will characterize the competent public health nursing agency. Records bear a definite relationship to both cost and quality of nursing service. The maintenance of accurate business records of nursing activities and results is an application of good business methods. The Visiting Nurse Association, in co-operation with the Bureau of Public Health Nursing of the State Department of Health has spent considerable effort in improving its record system. It would greatly facilitate the work of the nurses of the board of education and of the board of health if modern record systems were introduced.

The importance of the whole nursing program depends upon the personnel who are to carry it out. This in turn depends not only upon their personality, but also upon their adequate professional preparation. Minimum qualifications have been developed and approved by the American Public Health Association and the National Organization for Public Health Nursing, and would be helpful to organizations in Meriden whenever a new public health nurse is to be employed. The public health nursing work in the city would be materially improved throughout if increased super-vision by a nurse especially equipped for this purpose were available to serve all the agencies. As previously indicated, the only supervision rendered at present is in the Visiting Nurse Association where the very busy director of the visiting nurse and tuberculosis work also serves as supervisor. The outstanding need is for a high grade supervisor, perhaps with an appointment as associate director, in the Visiting Nurse Association. It would be most helpful, if arrangement could be made also, whereby this super-visor might also serve in the same capacity for the two other groups of nurses in the city and aid all three groups in the development of a comprehensive staff education program.

Visiting Nurse Association.

Having discussed the nursing service as a whole in Meriden, it is desirable to consider finally the work of the Visiting Nurse Association in more detail. A bulletin of information published by the Association describes the organization and it is unnecessary to repeat the material contained therein but rather to consider special phases of the work. There is an active Board of Directors of 30 members, with a nurses committee, a transportation committee, a maternity and child hygiene committee, a tuberculosis committee, and a Christmas Seal Sale Committee. These committees have rendered a valuable community service as indicated in their reports and in the apparent results. This organization has been a powerful factor in the promotion of modem public health work, in the community and enormous credit should be given for the results obtained.

During 1930, 3,074 patients were cared for, as compared with 3,922 in 1931, distributed as follows:

	1930	1931		1930	1931
General	706	702	Child Hygiene	1,340	1,743
Prenatal	243	271	Pulmonary Tuberculosis	103	173
Postnatal	223	225	Other Tuberculosis	91	---
New Born	224	307	Tuberculosis Contacts	---	324
Other Communicable Dis.	144	177

The nurses' visits numbered 23,568 in 1930 and 27,435 in 1931, classified as follows:

	1930	1931		1930	1931
Medical	4,506	---	Prenatal	873	---
Surgical	1,269	7,048	Maternity	1,315	4,790
Chronic	1,722	---	Newborn	1,354	---
Communicable	495	---	Maternal Hygiene	714	---
Tuberculosis	1531	---	Child Hygiene	4,982	7,032
Contacts	936	3,008	In behalf of patients	1,755	2,643
Miscellaneous	2,115	2,914

As previously noted, the nurses assisted in 1930 with 100 deliveries, with 15 pre-natal clinics (63 patients), and with 52 child hygiene conferences (1,870 babies). These figures do not agree in all instances with those given in the child hygiene section because in this instance all data apply to the calendar year, whereas for comparative purposes it was necessary to use in the earlier discussion fiscal year data.

TABLE IX

Distribution of Visits in Per Cent

	Meriden	7 Conn. Orgs.	24 U. S. Orgs
Maternity Service
Antepartum	3	6	5.2 (5)
Postpartum and delivery	8	8	11.1
Newborn	5	7	11.1 (6)
Child Health Service
Infant	13	15	15.9
Pre-School	14	7	---
Morbidity Service
Tuberculosis	10	5	4.9
Other Communicable	2	3	7.2
Non-Communicable	26 (1)	36 (2)	34.3
Miscellaneous, Not Seen	19 (3)	13(4)	10.3
All Services	100.0	100.0	100.0
(1) Chronic 9
(2) Chronic 6
(3) Behalf of 8
(4) Behalf of 5
(5) 8.5, 1-11 days
(6) 8.0, 1-11 days

TABLE X

Distribution of Time in Per Cent

	Meriden	7 Conn. Orgs.	24 U. S. Orgs
Field Nursing Activities
Field Visits	48.0	60.0	49.0-50.2
Conferences or clinics	3.0	4.0	3.9-3.9
Hourly Service	--	1.0	--
School Service	--	1.0	--
Delivery Service	2.0	1.0	--
Related Activities
Educational and Organization	--	--	3.7-3.3
Office	23.0	15.0	19.6-18.9
Travel	24.0	18.0	23.2-22.7

From a study of the case cards and of the diagnoses of dismissed patients, it is noted that a fairly large number of chronic cases are carried, which involves a large amount of time. The large proportion of new cases referred by the family concerned or by friends in contrast with the number referred by doctors is somewhat striking. During 1931, on the child hygiene service, the month of March was the period when by far the largest number of new child hygiene cases were admitted, June being second, the number (34) being about 3 times as many as in each of 6 other months.

Among the outstanding needs, the question of increased supervision by a highly, trained public health nurse who would become associate director of nursing seems to be most pressing. This step should be taken before other new nurses are added to the staff. Increased attention should be given to problems of mental hygiene. Were a mental hygiene clinic available in the city, it would aid materially in the work. There is a felt need for outpatient clinic facilities at the hospital. Besides the nurses, the social workers also greatly feel this need. This service should include through co-operation with the dental society, a dental service for cases unable to afford private treatment. Some additional provision should also be made for proper treatment of crippled children and orthopedic cases, and a crippled children survey should be made to discover the extent of this problem in the city. Such a survey is beyond the scope of the present study. It would seem desirable that a well child conference be established in South Meriden, and that each of the well child, conferences have a physician in regular attendance on a paid basis. Under ordinary circumstances, if pre-school children are progressing well, two visits per year with periodic home visits by nurses to check on progress would seem adequate. Furthermore, home nursing visits in behalf of infants and pre-school children should be carefully planned in relation to each individual home condition, and the frequency of visits by the mother to conferences. A detailed study of case records shows that this problem deserves careful scrutiny.

The Visiting Nurse Association is rendering an invaluable service in the community and deserves the support which it received from various sources. The staff should be gradually increased as soon as feasible along the lines suggested above. For many pioneer developments of public health activities in the city, due credit should also be given. With minor changes in administrative procedures and with the recommended staff additions, Meriden's public health nursing program might easily become second to none in communities of its population class.

Special Problems.

Cancer.

Cancer is the second cause of death in Meriden, 49 deaths occurring in 1930. The death rate from this disease has increased during the past years and is higher than in the rest of the county, even making adjustments for deaths of non-residents in hospital. It is commonly recognized that many forms of cancer can be cured if discovered and treated in the early stages of the disease. The family physician is the key person in the cancer control movement. Upon his judgment the final result often depends. A community program, as outlined in the 1932 Manual of Community Health Organization of the American Public Health Association, involves:

1. Co-operation by the health department with the local medical society;

2. A careful study of the incidence and mortality of cancer, including data regarding cases treated hospitals and the end results;

3. Development and utilization of cancer clinic facilities and stimulation of annual physical examinations;

4. A comprehensive educational campaign for physicians, nurses, and the general public.

During the fiscal year 1930-31, 41 cases of cancer were hospitalized in Meriden for a total of 516 hospital days. Nineteen of these cases were fairly early cases, having come for treatment within three months of the time of first symptoms, but 12 were as late as from one to five years, and the remainder from 4 to 12 months after the condition was discovered. Thirty-five of the cases were classed as carcinoma, with two each for epithelioma, lymphosarcoma, and sarcoma.

Meriden lacks facilities for current statistical analysis of the cancer problem, clinic facilities for diagnosis, and educational facilities for stimulating the public as to the importance of cancer and the urgency of securing early diagnosis when symptoms are first suspected. The medical service by private physicians and the hospital provisions correspond favorably with most communities. There are needed some 600 visits per 100 deaths in a community by nurses or social workers in behalf of post-hospital cases.

Heart Disease.

In Meriden, as in most communities, heart disease is the leading cause of death, there being 51 deaths from this cause in 1930. This is one of a closely related group of maladies in which the heart, arteries,and kidneys are more or less affected by degenerative changes.

While there are no special clinic facilities in Meriden for cardiac cases, the medical and pediatric service beds in the hospital are open to heart cases. A total of 61 cases were admitted during the year for a median stay of 14 days, the total hospital days being 983 days.

The health department is the logical agency, were the personnel adequate, to prepare annual tabulations of deaths from heart diseases by age and sex, and maintain for this disease as well as for cancer and tuberculosis and other important diseases, chronological charts of death rates by years. Increasing attention should be given to cases of acute rheumatic fever and to syphilis. The largest percentage of heart disease cases among children arises from rheumatic fever. Nurses should have some responsibility for case finding, actual care and home service.

Present standards relating to necessary clinic service suggest that there should be 100 visits per 100 deaths on the average, with a ratio of 2 visits per patient registered during the year. There might be expected at least 3 hospital admissions in a year per 100 deaths from this disease, with a median length of stay of 30 days per case admitted. There is further needed convalescent home care and occupational therapy for cardiac cases if a well rounded service provided. In a considerable proportion of cases, more or less prolonged institutional treatment may be desirable and in another group of cases, or in the same group at a later period, nursing follow up in the home is essential.

Mental Hygiene.

There is no problem of public health which is more important and at the same time so difficult of solution as that which relates to mental hygiene. In the average family throughout a community, it is probable that the handicap due to mental maladjustments is as great as the handicap due to all other diseases and defects combined.

The first step in a community's determination to prevent mental and nervous disorders is to ascertain the size and scope of its problem, while the second step consists in a frank comparison of its own facilities for handling this problem with acceptable standards of facilities elsewhere.

A tentative set of standards has been worked out by the sub-committee on the Appraisal Form for City Health Work of the American Public Health Association, largely through the efforts of the National Public Committee for Mental Hygiene. These standards, attached to this report, represent a desirable goal in the light of present experience, but they may be modified from time to time as additional information is acquired. Furthermore, the Connecticut Society for Mental Hygiene and the Bureau of Mental Hygiene of the State Department of Health are prepared to aid local communities in an advisory capacity in formulating programs. There seems to be much interest locally in the need for mental hygiene service and it is suggested as a first step that a local mental hygiene committee be organized to study the opportunities in this field in co-operation with the State organization above mentioned. Such a committee might develop an educational program for the community and aid in the establishment of a mental hygiene clinic.

Thirteen institutions in the state courteously supplied information regarding Meriden residents in hospital during 1930. In five of these sanatoria there were 58 patients admitted during the year and 10 deaths occurred among Meriden residents. In September, 1931, there were 185 Meriden patients in these institutions for mental disease. Data from 4 of these institutions showed that 44 of the patients spent 8,853 hospital days in these institutions, and this figure represents only a small proportion of the total number. Hence, it is apparent that from the standpoint of hospital care alone, the mental disease problem places a heavy burden on the community.

A mental hygiene clinic in the community would be valuable for the detection and treatment of the milder cases of mental maladjustment, not sufficiently serious to require hospitalization but in urgent need of the highest type of expert supervision. Perhaps the provision of such facilities would prevent the development of more serious forms of disease among many cases. The more progressive juvenile courts are availing themselves in increasing numbers of psychiatric service for youthful offenders.

Another important phase of the work in mental hygiene is with pre-school children and their parents. To pre-school clinics come children presenting problems of conduct and personality. A majority of such children may be aided by the services of physicians and nurses who understand the handling of behavior problems. Furthermore, mental hygiene work should ramify through all public health nursing programs. Proper training of nurses in mental hygiene work makes more productive all of their work with individuals and families through better understanding of human psychology and teaching methods. It increases awareness of the significance of variations of human behavior and equips the nurse to assist in securing the proper care of the mentally sick in their homes or elsewhere.

Special classes in public schools for mentally retarded children are regarded as essentials in modern school departments. In these classes are placed children who cannot keep up in their grades with the average child of the same chronologic age. Because of frequent misunderstandings of the purpose and scope of "special classes", some of the approved practices in this field are outlined.

1. Special classes are designed primarily for pupils with intelligence quotients between approximately 72 and 50 who require more individual pedagogic attention than can be given in average classes.

2. Special classes should not be used for children whose maladjustment is primarily characterized by problems of undesirable conduct, unless there is also intellectual defect.

3. No child should be transferred to a special class until or unless an intelligence test has been administered by a person competently experienced in the use and interpretation of such tests.

4. Teachers of special classes should be specially trained for this work.

Industrial Hygiene.

The significance of preventive medicine and surgery as a factor in industrial production was completely unrealized in the United States 20 years ago. Accidents or disease brought on directly or indirectly by conditions of the factory environment, were treated individually as private cases and little or no attempt was made to formulate a plan for their relief or prevention.

It is a source of satisfaction that Connecticut is one of the five states (others being California, Massachusetts, North Dakota and Wisconsin) which includes a broad coverage of occupational injuries under its compensation law. The requirement for the reporting of occupational diseases provides a basis for constructive work in industrial hygiene, Section 2416 of the Revised Laws requires physicians to report to the State Department of Health all cases of "poisoning from lead, phosphorus, arsenic, brass, wood alcohol or mercury or their compounds or from compressed-air illness or any other disease as a result of the nature of the employment of such person." Prior to 1923, these reports were made to the Department of Factory Inspection and since the transfer to the Department of Health, reporting has been somewhat improved.

A most important step was taken by the 1927 Legislature authorizing the State Department of Health to investigate and make recommendations for the control of occupational diseases. In accordance with this law the Bureau of Occupational Disease of the State Department of Health was organized on a full-time basis. This is a sound progressive step which should be frought with far-reaching benefits to the health and economic efficiency of the State. The bureau is now equipped with a laboratory and a trained field staff with facilities for making necessary analysis of workroom environment of dusts, fumes, poisons, illumination, ventilation, etc., or any condition affecting the health of workers.

All employers coming under the Compensation Act must, of course, provide medical and surgical care for injuries or diseases directly resulting from conditions of employment. What we are here interested in is the extent to which employers have gone further and have made constructive provisions for medical and nursing service and safety organizations as a preventive of disease and injury and for the positive promotion of efficiency.

In general, it may be said that from the state standpoint, Connecticut has a good compensation act and in the Bureau of Occupational Diseases of the State Department of Health an excellent foundation for the expert guidance so much needed in this important field.

In considering the possibilities of an industrial hygiene program to be developed by the industries, the following items may be noted:

1. Provision of necessary sanitary facilities, including wash rooms, toilets, and locker spaces.

2. Positive knowledge of the working environment without which preventive measures cannot be wisely established. This implies actual analysis of workroom conditions, as to the amount and kind of dust, fumes, gases and the like, to which the worker is exposed, with periodic checks of ventilation and illumination.

3. Accurate records of all accidents and illnesses, with their causes.

4. Physical examination at time of employment and periodic re-examinations particularly where hazardous materials are utilized.

5. Employment of industrial physicians and nurses. In those industries too small to employ such personnel individually on a full-time basis, groups of industries employing 1,000 or more combined may unite in securing the desired full-time staff.

In Meriden, considerable work has been done in certain industries toward the provision of an industrial hygiene program and important studies have been made by the International Silver Company in co-operation with the United States Public Health Service. As far as can be ascertained, there are no full-time industrial physicians, but the plants maintain medical service on a call basis. Four nurses are registered with the State as industrial nurses, in addition to the nursing service rendered the International Silver Company by the Visiting Nurse Association.

Popular Health Instruction.

Education of the public in the principles of healthful living and disease prevention is a most important function of a health department. Every opportunity should be utilized to keep the people informed of health activities and of the developments in the public health field. Modern public health practice has shown how to prevent a large portion of sickness and premature death. The problem is how to make this knowledge accessible to the average person in terms which he can understand and make a part of his own living. The direction of this work on a community basis is first of all the responsibility of the health officer. But unless a community provides a sufficient salary and security of tenure of office for a health administrator on a full-time basis, it can hardly expect a well organized, carefully conducted program of health instruction.

Public health instruction methods have gradually been developed to reach the people who need to benefit from scientific discoveries and health activities. The media available are numerous, and assistance may be obtained locally from the State Department of Health, Bureau of Public Health Instruction. Chief among the channels are newspapers, periodical bulletins, folders, pamphlets, magazines, radio talks, motion pictures, exhibits, posters, and public addresses. A well conceived educational program must be based on material of accurate fact, properly interpreted.

The health department distributed 2,300 pamphlets on communicable disease last year and the Visiting Nurse Association distributed literature on child hygiene and tuberculosis supplied by the State Department of Health, insurance companies and other sources. The daily newspapers published considerable material dealing with public health topics, although relatively few news stories were supplied by health agencies as is customary in many cities. There are no special health bulletins published locally and no special demonstrations of city-wide character to promote health.

There is considerable opportunity and need of public health instruction work in Meriden.

Accident Prevention.

In the vital statistics section, attention was called to the important position occupied by "accidents" as a cause of death. Many of the accidents, some of which are fatal and many of which are serious, occur in the home and a large group are preventable. The importance of home accidents needs greater stress. The Medical Examiner reports for the period April 11, 1929 to October 25, 1931, thirty-six deaths from automobile accidents occurring in Meriden or close to its boundaries. Relatively little outside of a routine nature has been done locally to lower this mortality There is opportunity for a more comprehensive safety education program in which the Chamber of Commerce, Service Clubs, Official departments, among other organizations might co-operate. Suggestions regarding the organization of such a program might be obtained from the National Safety Council.

Hospital and Medical Services.

Meriden is fortunate in having a modern general hospital with an experienced superintendent and active medical staff, with specialized services well developed, especially in medicine, obstetrics, pediatrics and surgery. The chief needs relate to medical social service, ambulance service, organized out-patient department services, and communicable disease hospitalization facilities. The medical board consists of 5 members. The laboratory is in charge of a full-time pathologist. The hospital is approved by the American Medical Association and the American College of Surgeons.

The hospital capacity is 112 beds and 24 cribs. Ninety beds fall in the $3 - $5 class, 4 in the $5 - $7 class, and 18 in the $7 - $9 class. The per capita per diem cost for the last fiscal year was $6.90. The weekly rate charged for city patients is $5 per day and extras, while a flat rate of $4 is charged for state patients. Even with these charges and the state and city ($16,000 a year), the annual cost of treatment of charity patients exceeds the income from state and city sources.

Weekly clinical conferences are held at which time interesting cases are reviewed and case problems are discussed. At the regular monthly staff meetings all hospital deaths are reviewed. The roentgenologist is employed on a part-time basis. A total of 791 hospital and 255 outside patients were examined during the fiscal year ending June 30, 1931. During that year, 2,322 patients were discharged, the classification according to type being as follows: medical 432; surgical 1,116; obstetrical 401; and newborn 373. Seven hundred and two of these patients were non-residents. Including outpatient cases and those admitted and discharged on the same day, there were 26,787 days of hospital care given during the year, the heaviest month being February and the lightest month June. The full-pay days numbered 3,665.

The outpatient department is small, as there is only one regular clinic, pre-natal, where 83 patients received supervision last year. Antiluetic treatment was given to 25 clinic-type patients who came by appointment. Practically all ambulant cases of the indigent class are treated by the city physician employed by the Department of Charities, or by private physicians in their offices. The need for a trained medical social service worker in the hospital to aid in the supervision and follow up of discharged cases in addition to other hospital social service duties is apparent. There is an acute need for an adequate ambulance service. Communicable disease cases needing hospitalization are sent to Hartford or New Haven, the local provisions being inadequate for routine care of patients of this type. The need of facilities for adequate care of chronic and convalescent cases is generally recognized by the physicians, the hospital, and the public health nurses of Meriden.

Inspection Service.

The inspection service provided locally for Meriden is handled by one inspector, a veterinarian, who devotes most of his time to the various aspects of food supervision, including milk, meat, and other foods. In addition to these responsibilities, the inspector is required to make general sanitary inspections, investigate nuisance complaints and to aid in the sanitary control of swimming pools. He also engages to some extent in veterinary practice. Obviously, the scope of work is too extensive for one inspector, on a part-time basis, and operating on a limited budget of less than $2000. For a reasonably effective inspection program, a full-time, trained sanitary and food inspector is needed in addition to part-time meat inspection service.

Milk Supervision.

From 13,000 to 15,000 quarts of milk are distributed daily in Meriden. This product is obtained from over 1,800 cows owned by 175 producers who serve 60 distributors. About 57 per cent of the milk supply of Meriden is not safeguarded by pasteurization. The local inspector makes periodic visits to dairy farms, distributing and pasteurizing plants, and collects samples of milk to be tested in the State Department of Health Laboratory in Hartford. It is also his duty to insure that all herds from which milk is supplied to the city are regularly tuberculin tested. A serious defect in this service is the lack of scores and of records of findings of inspections. It also seems apparent that licensing of producers and distributors is incomplete. The milk regulations of the city are reasonably satisfactory.

Four State agencies share in the supervision of milk supplied to Meriden. The State Dairy and Food Commission maintains a registration list of all dealers and producers; issues permits for the operation of pasteurizing plants and for the sale of Grade A milk; makes periodic checks of pasteurizing plants and annual inspections and scores of all producers and distributors, and offers advice and follow-up service to dairy men to secure improvements. The Bureau of Laboratories of the

State Department of Health conducts chemical and bacteriological analyses (467 in 1930) of milk sold in Meriden. The State Commissioner of Domestic Animals conducts official tuberculin tests, records and certifies tests made by approved veterinarians and accredits herds and areas meeting the requirements. The State Milk Regulation Board defines basic requirements for certified, Grade A raw and Grade A pasteurized milk in Connecticut, its activities being carried on by the State Dairy and Food Commissioner.

The State Dairy and Food Commissioner's program of milk control. Local communities have a definite responsibility for the supervision of their milk supplies It is found, however, that a large amount of work is done by the State in the Meriden area. In all, the State officials made 328 in inspections of dairies and milk plants supplying Meriden, or three-fourths of the number reported by the local inspector. The 6 pasteurizing plants and a number of dairies and milk plants were inspected by the survey staff in company with the local inspector. A detailed report of findings was made to the Board of Health. The most universal defect with the pasteurizing plants is the lack of provision of, and insistence upon the use of, adequate hand washing facilities, and in some instances of proper toilets. Furthermore, the handling of two or three grades or classes of milk by each of several pasteurizing dealers increases the difficulties of plant operation and control, and furnishes loop-holes through which high standards of safety may be more readily broken down. In general, the sanitary condition of raw milk distributing plants corresponds closely with that of pasteurizing plants. Most of the defects could be corrected by careful attention and relatively little capital outlay.

Among the milk producers, many lack satisfactory, stable ventilation equipment or design, facilities or methods for proper cleansing of milk utensils, and facilities for satisfactory refrigeration of milk directly after milking. There is opportunity on the dairy farms for considerable improvement in privy sanitation.

A classification of bacteria counts of samples of milk collected in Meriden reveals fairly satisfactory results for the limited number of samples analyzed. These results showed in general somewhat lower counts for the pasteurized than for the raw samples. It should be pointed out that the sampling of milk of individual producers and distributors of milk in Meriden, is much less frequent than is considered essential for reasonably satisfactory supervision. It is fair to state, however, that during the past five years considerable progress has been made in the supervision and improvement of the milk supply of the city, and these results compare favorably with other communities of this size in the State.

Supervision of Foods Other Than Milk.

There are approximately 40 restaurants and lunch counters in Meriden, most of which are given a casual inspection monthly by the local inspector. No records are maintained to show the type of inspection made, the nature of the findings, or the recommendations for correction of defects. There is no licensing system, although such a provision is considered fundamental for the institution of satisfactory supervision methods. The State Sanitary Code contains excellent rules for the sanitation of food establishments and these should be enforced in Meriden.

Somewhat casual inspections are made of soda shops, bakeries and markets, but the principal supervision of bakeries and ice cream plants is given by the State Dairy and Food Commissioner. There could be considerable improvement in the sanitary conditions of many soda shops, especially in regard to methods of sterilization of eating and drinking utensils and to hand washing facilities. A large proportion of the meat sold is inspected by Federal officials. The remainder is inspected before, during or after the local slaughtering, practically all of which to occur in the municipal abbatoir. Meat exposed for sale is also inspected in markets.

A serious deficiency in the local field inspection of all types of food handling, serving and selling establishments is the lack of adequate records of findings and needed corrections. Nearly all establishments, except a very few restaurants, show lack of facilities for, or practice of, hand washing. The majority of places are also deficient in care of garbage and refuse, and they expose too much food to flies, dust and human contamination. The local program of food supervision should be considerably strengthened.

General Sanitation.

After discussion of restaurant, soda shop, market, meat and milk control, relatively little remains to be said in the field of general sanitation. In addition to his food and milk control responsibilities the inspector is required to investigate all types of nuisance complaints and to aid in the checking up of swimming pools. It is impossible to determine the exact numbers of such activities. It would appear not out of place to suggest that the keeping on file of definite reports of the findings at each individual inspection, as advocated throughout other portions of our survey report, would not only permit more accurate control of each establishment, but would also somewhat facilitate the bookkeeping activities of the inspector.

About 60 inspections per year are made to investigate specific nuisance complaints of a widely miscellaneous character. Nearly all of these are judged by the inspector to reveal actual nuisances or violations of by-laws. In addition to the 60 inspections on complaints, about 15 reinspections were made at the same places last year. Practically no routine back yard, tenement or housing inspection program is carried on. The monthly reports showed a total of three tenement house inspections during the year.

Swimming Pools.

Meriden has two indoor swimming pools and three or more swimming holes widely used at certain seasons. Both the indoor pools have re-circulation pumps and pressure mechanical sand filtration apparatus. Neither has a gas fed chlorine applicator, but chlorine-containing solutions are added directly to the pools periodically. Both pools are inspected occasionally by engineers of the State Department of Health who inquire into operating techniques, take acidity and free chlorine readings at various points in the pools, collect samples for laboratory bacterial analysis and offer instructions and recommendations to the operators, including advice and instruction in operating the pools. The local food and milk inspector visits the pools approximately monthly (18 "swimming pool inspections" were-contained in 12 monthly reports of the inspector to the health officer) and collects samples for bacterial analysis. Reports on 27 samples analyzed in 1930 were found on file at the State Department of Health Laboratory. The Meriden swimming pools appear to have been operated in such a way as to maintain an excellent quality of water. There is considerable room for improvement of the sanitary conditions of the outdoor swimming pools and surroundings.

The general impression of swimming pool sanitation is that the indoor pools are apparently operated with a satisfactory quality of water and that outdoor places, while neither very good nor very bad, exhibit a lack of sanitary supervision, require improved toilet facilities in places and would repay well-planned bacteriological research. They should be regularly inspected during warm weather by a sanitary inspector.

Sanitation.

On the whole, it would appear that camps frequented by Meriden children are the object of serious effort at good sanitation on the part of their directors, though some are still rather limited in fundamental equipment. With one exception, they are regularly inspected by the State Department of Health. We would suggest that operators of the day camp of the Girl Scout Council arrange in the coming year for similar inspection service, and that both camps located in town be occasionally given a sanitary inspection by the Meriden inspector, and checked to see that Regulation 109 of the State Sanitary Code is complied with.

Water Supply.

Provision of an adequate water supply is one of the most fundamental needs of any community. For complete satisfaction, a public supply should be ample in amount for regular and emergency usage in all seasons, available at adequate pressures in all parts of its distribution system, bacteriologically safe in freedom from disease producing organisms, chemically free from substances unfavorable to industrial or domestic usage and physically pleasing to sight, smell and taste.

The Meriden water supply is municipally operated under the Water Department. It is a surface supply involving six reservoirs organized into three main systems. Flow from the distributors is by gravity; two of the three systems require pumpage in order to fill the distributors.

The average daily water consumption lies between 3.5 and 4.0 million gallons. The total figure for 1929 reported to the Public Utilities Commission was 1,264,763,500 gallons, supplied to an estimated 32,800 consumers, represented by 6,292 service taps. This gives for all days of the year an average consumption of 3.465 million gallons daily or 106 gallons per consumer per day. The 1930 consumption was 3.8 million gallons per day. These figures are only very little higher than the standard accepted by American sanitary engineers for city water consumption and probably indicate that no exceedingly large leaks nor grossly excessive wastage are occurring. It may be noted that the combined storage of all reservoirs is somewhat greater than the 1930 total consumption.

Population Served.

Effort has been made by the city administration to have the public water supply as universally available as possible. The inner zone (city proper) is estimated by the city engineer to be from 90 per cent to 100 per cent served by city water. The outer taxation district is relatively little served, although the distribution system has been much extended recently. The city engineer estimates that not over 20 per cent of this outer area is city supplied. For the entire political area, both taxation districts, public water service amounts to about 86 per cent of the population. The industrial consumers are metered. Metering of domestic users is about half completed and is progressing at the rate of 160 to 210 per year.

Sanitary Control.

Control of safety usually involves three principal measures: (1) keeping the watersheds as free as possible of both permanent and incidental sources of pollution; (2) provision of one or several methods of treatment directed toward the reduction of bacterial numbers and (3) maintenance of a constant check on results by means of routine laboratory analysis of samples. All three methods are, represented in the case of Meriden.

Attempts to prevent access of pollution to reservoirs constitute watershed control. In complete practice, this would include periodical thorough sanitary inspections, abolishment of permanent nuisances and efforts to reduce the chance of incidental trespassing sources of pollution by means of caretaker patrol of the watershed, fencing, posting of signs, prohibition of picnicking, fishing, bathing, boating and the like. Most of these measures are practiced to some degree by Meriden.

Inspection.

Routine inspection of the watersheds is not performed by Meriden. However, as is the custom elsewhere in the State, the entire water watershed is thoroughly gone over at least once a year by a sanitary engineer of the State Department of Health, accompanied by local water department officials. Record of all dwellings is kept spotted on geological survey maps and each property is visited checked with regard to the number of people and of livestock inhabitants, and examined as to sewage and other drainage disposal methods and conditions. Recommendations for correction of any permanent hazards are made by the engineer and their enforcement is a responsibility of Meriden.

In any community seriously attempting to protect the health of its citizens by careful safeguarding of the public water supply, watershed sanitation and water treatment are followed up by repeated laboratory examinations for a control on the quality of water actually delivered to the public.

For Meriden such laboratory work is done by the Bureau of Laboratories of the State Department of Health. Sample containers are furnished by the laboratory at least once a month and specimens of water from the different systems are collected therein by members of the city engineering staff. Moreover, occasional samples are collected by representatives of the State Department of Health. During 1930, record of 46 such samples has been collected by the laboratory.

A large majority (85 per cent) of the residents of Meriden are supplied with water by the municipality. The total supply available appears adequate. Distribution is widespread and satisfactory. The watersheds are favorably located, quite free of permanent sources of pollution, more liable to pollution by trespassers, not well fenced or posted, nor regularly patrolled and not generally pine-forested. The water from all three systems is chlorinated, but with methods and checks in which considerable loop-holes exist for which immediate improvement is desirable; the largest supply is also protected by rapid sand filtration. The bacterial safety of the water is checked by monthly laboratory examinations, which in 1930 showed that the composite of 46 samples about equalled the standards which the United States Public Health Service applies to water used by interstate carriers. Total bacterial content was low. Chemical and, physical qualities were favorable.

Private Water Supplies.

In the "city proper" (second taxation district), there are very few wells or springs. In the outer area at least four-fifths of the people must find their own sources of water. Driven and to some extent drilled wells are reported to be the prevailing types of supply. These private water supplies have never made the objective of a sanitary control program involving field inspection and education of the people in location and protection of their supplies. Hence it is probable many homes might be found to have wells or springs inadequate in casing, curbing, covering or pumping provisions.

Zoning.

In order to protect the welfare of its citizens by controlling the character of future development of the city, Meriden in 1927 adopted a zoning ordinance. The objectives of the program are "to promote health safety, convenience and general welfare.'' The principal features stipulated are as follows:

The city is divided into districts devoted to six types of occupancy, use and development. In each district appropriate regulations govern the legitimate uses for buildings, control the minimum size of yards and alleys, from which light and air are supplied, determine the percentage of lot area that maybe built upon, the area of each lot per family and the height of new buildings. In certain instances, provision is made that height may be slightly increased if the buildings are set back an extra distance from the street. The length of chimneys, tanks, elevators ornamental towers and the like is not limited. Special provisos to meet specific conditions have been included in the ordinance. Existing uses are not stopped, but changes must tend toward conformity with the regulations.

In general, the zoning movement appears to be progressing satisfactorily, although it is somewhat handicapped by lack of an earlier start. In order to avoid hardship on any unusual cases which may arise and to overcome disagreements, provision has been made for a Board of Zoning Appeals. Opposition so far encountered has tended to be on the side of resisting admittance of any possibly undesirable feature to a district rather than the claiming of injury or unjust discrimination on the part of a project seeking to enter a zone. ln other words public pressure as reflected in hearings before the Board of Appeals, is against rather than for leniency or break-down of district limitations.

Administrative enforcement of the zoning ordinance is vested in the Building Inspector's Department. Compliance of proposed structures to the zoning code is one of the prerequisites for approval of plans by the Building Commission.

Streets.

Valuable improvement has occurred in the past two years from the construction of the concrete State Highway through Broad Street, which is effective in relieving traffic congestion from the center of Meriden and in expediting trunk travel between Hartford and New Haven.

During the past year or two, considerable unsatisfactory wooden or brick pavement in the principal streets has been replaced by very good asphalt surface, with an effect highly pleasing to both motorists and pedestrians.

Street cleaning operations are conducted by the street department under the Superintendent of Public Works. A motor sweeper was discontinued after a very few years' use and none is now operated. With the advent of universal motor vehicle transportation and the nearly complete exodus of draft animals, much less sweeping is needed. Dust blown by auto traffic to the gutters is washed away by the rains (many streets are hilly) and little dirt remains.

Building Control.

Building construction is under the control of a Board of Building Commissioners consisting of three members. The executive agent is the Building Inspector.

Attention is concentrated in the main, on new construction. Plans and specifications must be on file six months before building. They must be approved by the Board of Building Commissioners. For approval, proposed construction must comply with:

a) the Meriden Building Code

b) the Meriden Plumbing Rules and Regulations

c) the Meriden Zoning Ordinance

d) (d) the "National Electrical Code" of the National Board of Fire Underwriters

The present building code is admittedly out of date. The deficiency in building code was recognized when the present mayor assumed office and its correction made an objective, with the gratifying result that new, complete and revised code is stated to be under compilation.

Inspection activity is directed mainly toward new buildings in the various installations are observed during construction and at the end for a final passing of approval. Inspection is also made of new installations or alterations and repairs in existing structures.

At present there is no consistent program working toward the reviewing or routine inspection of old buildings. Inspection of public or other buildings for fire hazards is a function of the fire department, which reported 1,400 inspections and 50 re-inspections during 1930. Routine sanitary inspections of tenements, back yards or cellars are not made, but complaints of such nature are investigated by the Food and Milk Inspector of the Health Department. A canvass of existing buildings to check electrical conditions is said to be under consideration.

During the year 1930, 706 building permits were issued. Over 50 per cent of these were for additions, alterations and repairs. New construction was led by garages (92 wooden and 30 fire-resistant), and one-family houses (58 wooden and 8 fire-resistant).

Collection and Disposal of Garbage, Refuse and Ashes. Collection.

Collection of garbage and ashes is municipally operated in Meriden. Formerly handled by contract let by the Health Department, collection has in recent years been performed, as it more properly should be, by the Department of Public Works. It is stated that only one private collector is now operating and his function is confined to the area lying outside the Second Taxation District, or "city proper".

For facility in collection, the city is divided east and west from the railroad, each half being visited twice weekly on a fixed schedule of days. Only motor trucks are employed, three being used in the summer and four in the winter. The trucks have metal, supposedly watertight bodies and are said to be covered with canvas while en route to the dump.

Property owners are required by city by-laws to separate garbage from ashes and other refuse and to provide for garbage suitable, covered receptacles "approved by the Health Officer". Truck drivers are required to replace covers after collection and the by-laws request property owners to remove the emptied cans from the street front within five hours after the contents have been removed. That there is, however, room for improvement was apparent in some instances encountered in our own field inspections, particularly in the case of restaurants and food stores, where containers were often not "suitable", not properly covered, and not always well separated as to contents.

A few downtown establishments retain a special arrangement carried from the days of contract collection, whereby for a fee of $1.50 per month, backyard collection service instead of curb service is provided by the city.

Most of the meat and fish markets have special, private arrangements with a rendering works for daily removal of their scraps and offal. Bulky rubbish and trash from homes are not ordinarily removed by the regularly, semi-weekly collection trucks. Disposal of such material is the personal problem of the householder, with the exception that each spring a clean-up week is conducted, during which time the city arranges to remove all rubbish from premises desiring the service.

The total city appropriation for the collection and disposal of garbage, rubbish and ashes was in 1930 in round numbers $17,300, or $0.45 per capita, a low figure in comparison with certain other Connecticut communities.

Disposal.

Disposal of garbage and ashes at Meriden is by dumping. A fine example of what can be accomplished by determined forethought and planning has recently been developed in this situation. A former dump on Lewis Avenue, insufficiently removed from houses, schools and play grounds was a definite "eyesore " for years. Smouldering fires proved largely unquenchable for long periods. The present administration determined to close this 40 year old dump and convert it into a playground.

Last spring funds from a special bond issue were used to put to work on the dump a crew of unemployed laborers, and covering was speedily effected. The surface has been grassed over and will be opened as a playground in 1932.

The new dump has been established in South Meriden, more than three miles from the center of the city. It is located south of the airport and adjacent to the filter beds of the sewage disposal plant. Filling has been directed purposefully. Already the aviation field has been expanded by the filling of one section, the level of which had in past years been lowered to provide sand for the filters.

A full-time caretaker is available at the dump to direct disposal. Some attempt is made to locate paper and other combustibles in a wire fenced pen about 75 feet in diameter where they are burned, thus relieving the rest of the dump of considerable material likely to smoulder. The location is sufficiently remote to preclude formation of any major nuisance and the program seems wholesome, constructive and intelligent. We may conclude that the past year has seen enormous changes for the better in Meriden's disposal of refuse.

Promiscuous Dumping.

The center of the city appears quite free of promiscuous, uncontrolled vacant lot dumping. Several such spots, however, were noted at various points, where vigorous co-operation between the health department, police or others might yield results fruitful in the field of civic betterment. Relatively few complaints of promiscuous dumping are received by the city officials. Several scrap heaps for metallic wastes were noted during our field inspections. These, however, are an esthetic rather than a health problem.

At a few points along the stream, small dumps have arisen on the banks in violation of the State Sanitary Code and State law. The Meriden City By-Laws and the State law also prohibit the dumping of garbage or other putrescible material into watercourses.

It would appear that during the promotion of public works to relieve unemployment, some energy could profitably be expended on the cleaning up of the river bed. Possibly by closer co-operation between a sanitary inspector and the police, the abolition of promiscuous dumping could be effected or its covering rendered more complete. We regard Meriden's status on this point as not critical or deplorable, but still subject to definite civic improvement.

Sewerage, Sewage Disposal and Stream Pollution.

The advent of the "water, carriage system", whereby sewage and all domestic waste fluids are removed from the home of each property owner by a network of municipally provided collecting pipes and carried to a common, remote, disposal site, marked a major advance in the development of community sanitation, promoted a definite improvement in health protection and provided a civic benefit widely recognized as one of the advantages of urbanization. In the institution of such a progressive step, Meriden justly claims a pride in early priority. It is believed that Meriden's collecting sewerage system leading to disposal through several acres of sand filter beds, put into operation in the early nineties, was one of the first major installations of its kind in this part of the country and perhaps the first extensive filtration plant in Connecticut.

Since the early start, both the sewerage system and the treatment plant have been somewhat expanded, but in late years have not kept full progress with the growth of the city, until now both system and plant are in some points inadequate for their load and cannot perform their function to the full. Increasing pressure for needed improvements, particularly in disposal methods, has been forthcoming from the State Department of Health (Bureau of Sanitary Engineering) and the State Water Commission. Only this past year, Meriden has taken the first essential step to restore itself to a position of excellence in sewage disposal, namely, the securing of a careful study of present capacities, present demands and future needs in this aspect of sanitation. To such end, a sewerage survey has recently been completed by the firm of Fuller and McClintock, consulting sanitary engineers of New York City. Their report was submitted to the city under date of September 18, 1931.

Since that report has covered the field more intensively and with more consideration of engineering detail than be possible to the present public health survey, we feel that a brief review of the main findings therein will constitute a favorable handling of the subject for our present purposes.

Sewerage.

Type.

The city is served by the separate or sanitary type of system, whereby carriage is supposed to be confined exclusively to domestic wastes of sewage proper. About 50 miles of such sewers are now extant. Separate sewers for storm water have been and are being developed; they deliver to Harbor Brook or its branches instead of to the disposal plant. The estimated length of storm sewers is approximately 35 miles.

Flow studies indicate a rather rapid response of the sanitary system to rainfall, suggesting that more storm water than desirable is entering the sanitary system. This may be attributed to three or four sources. Some private sewers early absorbed to the municipal system may have originally been of the combined type, for both sanitary and system where storm wastes. Some roof and cellar drains may have similarly gained the same access, though it is doubtful if many instances of either kind have been accepted in the last score of years. A third possibility, known to be true at one or two points, is that certain sanitary sewers may leak more than is usually considered permissible, hence, allowing the infiltration of considerable ground water. Finally, some manholes of sanitary sewers may be located at points where flooding of streets with storm water permits it to overflow into the manholes.

It is the belief of the consulting engineers, as well as the State sanitary authorities, that effort to reduce to the minimum the ingress of surface and ground waters should precede expenditure of money and labor to expand or reinforce points of the system where capacity is inadequate for storm flows.

Extent.

The inner circle, or "Second Taxation District" is completely sewered, bordering on 100 per cent served. Until about ten years ago, connection to the public system was allowed only within the "city lines". With the change in policy, expansion to the outer district began, but is nowhere near complete, although it is, of course, true that much of the outer area lacks sufficient house development add population congestion to permit of sound economical sewerage.

The most immediate needs for extension lie in two nearby districts near Main Street, one east and one west of the center, where several streets have been well developed in recent years. These two areas involve respectively approximately 250 and 125 acres and include about 125 and 175 houses. It is hoped to sewer these areas in the neat future with part of a special bond issue of $150,000 for sewerage and sewage disposal improvements, the labor to be pushed as part of the unemployment program.

South Meriden is a well developed little community of several hundred people; it is as yet entirely unsewered. Porosity of soil has made for efficiency of private disposal methods, but provision of a collection system in the future deserves consideration.

All in all, present population from both inner and outer tax districts connected to the public sewers is estimated by Fuller and McClintock as 29,000 out of 38,500, or approximately 75 per cent served.

Adequacy of System.

The existing system of pipes is reasonably adequate to carry the flow, with a few exceptions, as follows: At least one street sewer definitely leaks to excess and is known to admit too much ground water. This is the lateral in Capitol Avenue. It needs replacement with a watertight line, which ought to be larger in places to allow for the increased flow from the new West Main Street area, which, when installed, will flow through to the trunk. Two main sewers may, in the early future, though not immediately, need reinforcement. The trunk sewer is inadequate for maximum flows at three points, particularly at the Quinnipiac River siphons where too much raw sewage has often been "blown-off" to the river.

In review, the extension of sewerage at once to two areas ready for it, replacement of a leaky and inadequate street sewer, enlargement of the lower portion of the trunk, including siphons, elimination so far as possible of storm waters, and the reinforcement in the less immediate future of a couple mains represent the principal needs of the Meriden sewerage system.

Plant.

Sewage from the public collection system is, except for portions blown off at the siphons for raw discharge, delivered to the sand filtration plant at South Meriden. The early establishment of this plant nearly forty years ago has already been referred to as a pioneering achievement to the credit of Meriden. For some years operation of the plant has been unable to accommodate the entire sewage flow, except perhaps very temporarily in the driest periods.

Sewage Flow.

The total dry weather sewage flow is estimated by the State Department of Health to be slightly less than 3 million gallons per day. Water consumption as discussed elsewhere, is from 3.5 to 4.0 million gallons daily. The 1929 studies of the State Department of Health indicated that maximum filtration capacity for the beds could be maintained for a time during dry weather at 2.3 m.g.d.

Operation.

Both the State Department of Health and the Consulting Engineers feel not only that the plant is of insufficient capacity, but that its capacity has not been used to the full and could be increased by better operation. The State sanitary engineers have repeatedly urged heavier application to the beds, which have been for years operated on a constant one-week cycle, the same beds the same days in the week.

The statement that the engineering consensus that the inefficiency of the plant could be (and ought to be) considerably increased by better operation, should be qualified somewhat. "Better operation" should be interpreted to apply to productive features, such as heavier dosage, shorter cycles, better grading and the like, rather than to more esthetic considerations regarding conditions at the plant. For instance, when seen by a member of the survey staff, the dry beds appeared very clean, there was no foulness in the air, the effluent was very clear, and so on, items which from a point of view other than productive volume efficiency are earmarks of good operation.

The plant is located sufficiently distant from the city or surrounding dwellings to preclude development of any major atmospheric nuisance.

Consideration of necessary changes in the plant, and installation of new equipment and methods for the ultimate development of a complete and satisfactory treatment works was carefully entered into by Fuller and McClintock. Pending opportunity to finance their complete treatment program, the State sanitary authorities feel that not all of Meriden's immediate activity should be expended on improvement of the sewerage system, but part should he directed towards temporary changes at the plant and river siphons whereby filtration can be somewhat increased and raw sewage discharge to the river diminished.

There is no regular or routine inspection service, educational program or practical field advice for private disposal methods. There has never been a "model privy" campaign nor do the sanitary inspector, city engineer or superintendent of public works know where a really model privy could be found in town. Those seen in our own dairy inspections or while engaged in other inspection work would hardly pass the definition. One fairly concentrated and populous community served very largely by privies is located at South Meriden.

To the credit of the city, it should be added that privies have been quite completely eliminated from the inner taxation district. Very few can be found even by search of a considerable area. No privies overhanging the banks and directly discharging into streams were noted by our inspectors. However, nuisances from absence of privies or from privy substitutes have been known to occur on the banks of some swimming places. The city by-laws require all property owners to connect to public sewers wherever available and to remove, refrain from building or discontinue use of privies thereafter. The laws also require that all privy-vaults and cesspools within in the city limits shall be cleaned out at least once a year, between January 1st and June 1^st. No person can remove or transport contents of such without a license; he must employ closely covered water-tight containers during conveyance. No privy vault shall be less than 18 inches or more than 36 inches deep, without written consent of the health officer. That all of these rules get active enforcement at the present time may be questioned.

Trade wastes in Meriden are very largely disposed of by discharge into the watercourses, mainly Harbor Brook and its tributaries. The amount probably exceeds 0.5 million gallons daily. Considerable industrial pollution, therefore, occurs, and discolorations can readily be seen at points. However, on account of the preponderance of metal work, plating and other hardware manufacture among Meriden industrial activities, the majority of wastes are of an acidic, metallic, or other inorganic chemical nature. This means that, even heavy trade discharge, while esthetically undesirable and unclean, capable of rendering the stream unsightly and unfit for other uses, and in all regards definitely to Meriden's civic improvement to clean up, does not result in nearly so severe a nuisance as would occur if putrescible organic matter was discharged in far less quantity.

Some of the Meriden wastes are undoubtedly of a chemical nature unfavorable to biological methods of sewage disposal, such as filtration or sludge digestion, and it is probably preferable at present that should not go to the plant, unless certain preparatory steps were taken at the factories.

Tendency towards occasional, and in places objectionable, dumping of rubbish, garbage or other wastes in the stream or on the banks has been referred to in a section of the report covering refuse disposal. Prohibition of such a practice has ample legal background both in the State laws and Sanitary Code, and in the Meriden by-laws. Undoubtedly its enforcement could be made somewhat more active and complete, with attendant civic betterment.

THE JOURNAL PRESS

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