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without such assistance as he can furnish. In this way his aid is extremely valuable in the identification of diseases, against the contagion of which the community should be protected so far as it is possible to afford such protection.

Except for examinations of diphtheria swabs, no such work has heretofore been undertaken by the Colorado State Board of Health, but following the practice which has obtained for a decade in some of the more progessive States and which has recently been adopted in many others, it has been decided to extend our work in this direction, thereby fulfilling to a larger degree our obligations to the people of the State.

Therefore the following bacteriologic examinations will be made for practicing physicians and health officers without expense, except the cost of transportation either by mail or express, as the nature of the specimen may require or the postal laws necessitate:

1. Examination of swabs of suspected diphtheria.

2. Examinations of sputum for tubercle bacilli in suspected tuberculosis. 3. Examinations of blood in suspected typoid patients by Widal or cultural methods; also examination of urine and feces.

4. Application of the virulence test in case of diphtheria "carriers" to determine whether they are infective for others.

5. Examination of spinal fluid for the meningococcus.

6. Examination of the central nervous system of animals in suspected rabies. Note. All examinations in cases of suspected venereal diseases are done through the division of venereal disease of the State board of health.


The following rules have been drafted for the instruction of those sending specimens for examination by the State bacteriologist. Failure to comply with these rules will probably prevent the examination of the specimen.

All specimens examined must come from persons resident in the State of Colorado.

These examinations will be made only on request of a health officer or practicing physician in the State of Colorado.

No charge will be made for the examinations detailed above. It will be necessary, however, to insure attention that specimens be sent by the proper persons, with charges fully prepaid and that complete and accurate data accompany each specimen. The postal laws forbid the sending of diseased tissues, sputum, etc., by mail except in containers approved by the postal department.

All specimens sent should be securely wrapped and packed so as to guard against leakage or breakage of the container with consequent danger to those handling them.

Direct such specimens to the State bacteriologist, Denver, Colo.

Reports will be made as promptly as possible depending on the exact nature of the material to be examined. Those wishing reports made by telephone or telegraph at their own expense must so indicate when sending the specimen.


Fill out carefully all details of the case on the accompanying card.

1. Diphtheria swabs.-Swabs should be taken with care, using outfits furnished by the State board of health. These may be obtained from the local health officer or from a local outfit station under his control. Culture will not be examined unless the blank is properly filled out. The outfit should be re

placed as when first opened and mailed, postage prepaid, to the State bacteriologist, Denver, Colo.

2. Tuberculous sputum.—This must be sent in bottles containing 5 per cent carbolic acid, as furnished by the State board of health and obtained from the local health officer or local outfit station under his control. The early morning expectoration is to be preferred; when this is not sufficient in amount, that expectorated later may be added. Before obtaining the specimen the mouth should be thoroughly rinsed with water to avoid the admixture of particles of food. Retain the carbolic acid solution in the specimen bottle and cork tightly to prevent leaking. The bottle should be replaced in the outfit package and mailed at once, postage prepaid, to the State bacteriologist, Denver, Colo.

3. Typhoid blood.-The Widal reaction, if done before the end of the first week of fever may be negative even in cases of true typhoid infection. A single negative Widal at any time does not exclude typhoid absolutely but only renders its existence doubtful. Tests within the first week should be by blood culture; this can be done only in ambulatory cases which can present themselves in person to the State bacteriologist. The blood of patients who have received prophylactic injections of typhoid vaccine within two years and in some cases longer, will show a positive Widal reaction; in all such cases blood cultures must be made to determine a typhoid infection. Since the Widal reaction is a quantitative one, using but a single drop of blood, exactness must be observed in following the directions which accompany the outfit furnished by the State board of health. This may be obtained from the local health officer or the local outfit station under his control and should be mailed without delay, postage prepaid, to the State bacteriologist, Denver, Colo.

4. Suspected spinal fluid.-Specimens of spinal fluid for examination for the meningococcus must be secured under strict aseptic precautions in either a sterile test tube or vial and mailed in a proper mailing case to the State bacteriologist, Denver, Colo.

5. Suspected rabies.—If an animal shows signs of abnormal irritability, restlessness, snappishness; or, if it be a dog, of overplayfulness; or of dullness, shyness, or loss of appetite; or if it barks very frequently in a short, abrupt manner, rabies may be suspected. In some cases an unnatural appetite with attempts at eating shoes, doormats, clothing, leaves, articles made of wood and the like may be noticed, as foreign substances of such character have been found in the stomachs of rabid animals. Drooling or frothing at the mouth" may be seen; violence or convulsions may or may not be present. A frequent course of the disease is a gradually increasing weakness ending in paralysis and death.


When a person has been bitten, lacerated, torn, or scratched by an animal suspected of being rabid, the animal should be taken alive if possible and be kept closely and securely confined, fastened with a chain if necessary, for a period of two weeks, with good care. If the animal remains well until the end of the two weeks' period rabies may be excluded.

If the animal can not be secured alive is should be shot through the heart, and never through the head, as this may render impossible an early diagnosis by injuring those structures in which are found the Negri bodies whose presence constitutes positive evidence of the disease.

The importance of securing the animal alive is seen in the fact that if a rabid animal is killed too early in the disease it may not be possible to demonstrate the presence of the Negri bodies, in which case the biological method must be used, so delaying for weeks or months a certain diagnosis. It should also be remembered that the rabies virus may be present in a dog's mouth five or

six days before the appearance of symptoms; therefore it is possible for a dog with no evidence of the disease at the time of the biting to communicate rabies. If a dog or other animal which has bitten a person either dies from rabies or is killed because of the disease, the head should be severed from the body close above the shoulders, care being taken by the person doing this not to become infected in the act. The head should be wrapped in strong muslin; it should then be chilled, or, better, frozen at once, and be kept as cold as possible until time of shipment. In preparing it for shipment the head, already wrapped in muslin, must be repacked in ice and sawdust in a small water-tight keg or candy pail, using sufficient ice to insure that it will be kept very cold during transit. Having marked the package "perishable" it must be sent by express, prepaid, to the State bacteriologist, Denver, Colo., at the same time sending a message by telephone or telegraph notifying him of the shipment. Do not ship so that it will arrive in Denver on a Saturday, Sunday, or a holiday, but be certain to keep it well iced until it can be shipped. Be sure to place on the package also the name and address of the consignor. A letter should be mailed at once giving the following data:

a. Name, residence, and post-office address of owner of dog (or other animal). b. Details of illness of the dog, noting unusual behavior as shown by change in disposition, unnatural appetite, etc.; also symptoms showing development of the disease.

c. Date of earliest symptom and date of death of the dog.

d. If the dog was killed, give reason for killing; manner and time of killing. e. Name, residence, and post-office address of other persons known to have been bitten by this same animal, with date of biting.

f. Any other known facts concerning persons or animals in any way related to this case.

Not all persons bitten by a rabid animal die, chiefly because the clothing partially protects them from the entrance of the virus, but the danger is very grave; therefore all persons who have been scratched, bitten, or lacerated by the teeth or claws of an animal known to be rabid should be given the Pasteur preventive treatment. Also all persons having on the hands, face, or elsewhere on the body wounds which may have become infected from contact with the saliva of a rabid animal; or who have been exposed in any manner to possible infection from a known rabid animal; or who have been exposed to possible infection from an animal suspected of rabies, or from one which, being suspected, has disappeared from home, has died, or has been killed, should receive the preventive treatment. The necessity for preventive treatment exists in all persons who have been bitten or otherwise subjected to possible infection by an animal within two weeks previous to the date when it was known to have been rabid; those bitten longer than two weeks before are in no danger. It should be understood that this is a preventive treatment only; it has no curative value if used during the course of the disease.

Supplies.-There shall be established by each local health officer, either at his own office or at some other convenient location, as he may determine, a local station where all swabs and other bacteriological supplies shall be kept, and the local health officer shall make known to all other practicing physicians in his territory the location of such station. All bacteriological supplies will be sent directly to the local health officer, who shall at all times control their distribution and shall be responsible for their safe-keeping. He should be careful to report from time to time to the State board of health, so that he may not be without such supplies as are necessary.

Hospitals, Dispensaries, Maternity Homes, etc.-Licenses-Keeping of Records-Making of Reports-Sterilization of Bedding, Clothing, and Utensils-Nurses-Approval of Building Plans. Maternity Patients-Care of. (Reg. Bd. of H., Nov. 8, 1920.)

REG. 56. Hospitals, sanatoria, lying-in hospitals, maternity homes, dispensaries, and other similar institutions.-RULE 1. Any hospital, sanatorium, lying-in hospital, maternity home, dispensary, or other similar institution shall be considered within the purpose of this regulation if it announces in any way that it will receive and care for, or if it is to be operated for, or if it is a matter of public knowledge that it is established to receive and care for persons who are sick or injured or any woman or girl approaching or during childbirth. RULE 2. Any corporation, association, person, or persons, before opening such institution shall apply for a license to do so to the State board of health, which will supply proper blanks for such application. A fee of $1 must accompany each application. This will be returned if the license is not granted. Licenses are issued only by order of the board at a regular or special meeting. A license must be posted in the office or other conspicuous place where it can be seen easily at all times. Any licensee discontinuing business must surrender his license to the board without delay.

RULE 3. All applicants for licenses must be of good moral character, capable, and trustworthy; they must also have a suitable place for conducting their business. The board will determine after inspection whether the place is suitable for such business.

RULE 4. For sufficient reason licenses may be refused or revoked: Provided, That notice of time and place of hearing concerning same shall be given to applicants or licensees.

RULE 5. Licensees whose principal business is receiving and caring for tuberculous patients must receive tuberculous patients only.

RULE 6. Licensees who receive maternity patients are prohibited from advertising their business in any daily or weekly newspaper.

RULE. 7. All maternity patients when in labor and for at least one week thereafter must be attended by a regularly licensed physician or licensed midwife and the moral and professional standing of either physician or midwife must be satisfactory to the board. When a change is to be made in the employment of a physician, regularly a member of the staff, notice of such change must be given to the board at once.

RULE 8. "No child shall be sold or otherwise disposed of for any valuable consideration by any of the persons subject to the provisions of this act," nor shall any child be given away for adoption or otherwise disposed of except by strict compliance with the statute governing such cases.

RULE 9. All applicants must give the name and address of the staff of physicians and surgeons in regular attendance upon the institution.

RULE 10. All licensees must keep a record in suitable form giving the name, address, date of admission, date of departure, and nature of sickness of each patient. In case of maternity patients the record must also show the expected date of labor, actual date of labor, name and sex of child, and what disposition has been made of the child. A record must be made immediately on admission of a patient and such record must be kept up to date by making additional entries each day as events occur. Said record shall be open at all times for inspection by officers or duly accredited inspectors of the State board of health. Said named officers and inspectors shall at all times have the right to enter any licensed institution for the purpose of inspection and investigation.

RULE 11. All institutions coming within the provision of this regulation, in addition, shall quarterly, on the 1st day of January, April, July, and October

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make a report to the State board of health of the number and names of the people in charge or employed in such institution, and if physicians," their name and address. Adequate nurses both in numbers and qualifications must be provided; noncompliance with this rule may cause the license to be revoked. RULE 12. It is required that a general healthful and sanitary condition shall be maintained at all times about both the buildings and grounds and that a recognized average cubic-foot air space per patient be provided with adequate means for ventilation. Especial attention shall be given to the cleanly and sanitary character of all baths, toilets and water-closets, and to methods of sewage disposal.

RULE 13. Some efficient means, approved by the board, shall be provided for the disposal of garbage and refuse. All garbage and refuse from institutions receiving or caring for tuberculous cases must be burned; institutions of this sort should construct an incinerator for this purpose.

RULE 14. All hospitals and sanatoria should have two separate diet kitchens; one for the preparation of food for managers, superintendents, resident physicians, nurses, and other attendants; the other for the preparation of foods for the patients. Fragments of food should not be returned to the diet kitchen but to an incinerator for this purpose. (See also regulation 65.)

RULE 15. Sufficient provision should be made for the sterilization of soiled bedding, clothing, and utensils used in typhoid fever and other similarly communicable diseases. Nurses should be carefully instructed concerning the danger of " infection by contact."

RULE 16. All hospitals and sanatoria should have constructed for them a suitable container in which to sterilize by boiling, the excreta of all patients affected with typhoid fever, paratyphoid, cholera, dysentery, tuberculosis, or other diseases in which infection is carried in urine or stools. Such sterilizer should be remote from the kitchen or any other place where food is either prepared or stored.

RULE 17. Nurses caring for this class of cases must not be permitted to attend to any duties in the diet kitchen in connection with the preparation of food for others.

RULE 18. Since the occurrence of typhoid fever is from 10 to 20 times as frequent in those nursing typhoid as in other persons not so exposed, and since paratyphoid is also of frequent occurrence, is transmitted by the same means, and can not be clinically differentiated in most cases, it is required that probationer nurses, on entering upon their duties in a hospital or other institution where typhoid cases are received, shall be given a combined prophylactic typhoid and paratyphoid vaccine unless they have either had these two diseases or have been so vaccinated within two years previous; and this shall be repeated every two years during their stay in the institution. It is required also that in any hospital or sanatorium, if any probationer nurse has not been successfully vaccinated against smallpox within five years previous, such vaccination shall be done immediately upon her entrance upon her duties.

RULE 19. Suspected "carriers" of disease of any sort must be excluded from service in kitchens, dining rooms, or dairies belonging to or in connection with any hospital, sanatorium, or other similar institution.

RULE 20. Ample fire escapes shall be provided in all hospitals, sanatoria, and other simliar institutions for the care of the sick and injured, and patients shall be given any necessary instruction concerning the manner of reaching such fire escapes.

RULE 21. Plans for the erection of hospitals, sanatoria, and similar institutions should receive the approval of the State board of health before the work of construction is begun.

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