EXHIBIT II.-Infant and maternal mortality rates, 1943, by sections of the

We are telling you one of our happiest stories. It concerns the wife of a United States marine. She called us (Public Health Nursing Service) in last September to help her. She had been in the hospital in California and had been flown east to be with her family. She was in the third month of her second pregnancy; the first was unsuccessful. There had been considerable doubt about her ability to conceive and even greater doubt as to the outcome of any pregnancy. Although she was with her family, she seemed alone, frightened, and terribly anxious to have this baby.

Under our guidance she went back to the Naval Hospital, where she had care during the first pregnancy, and was hospitalized for the next month. On her return, we visited to give her injections, thus saving her two trips a week to the hospital. She stayed at home in bed and we visited 27 times in the next 3 months until she was allowed up and injections were discontinued. We kept in touch wtih her through the rest of the pregnancy and had the satisfaction of helping her learn to care for her son who was born in March.

This mother perhaps took too great risk in having a child as a fibroid tumor made her delivery very hazardous. She was in the hospital several weeks and was gravely ill. To her and to her husband their son, whom they had been told they would never have, is a happy ending and we followed her pregnancy with more than usual interest. Since hospitalization for the entire pregnancy was out of the question, visiting-nurse service was essential for this mother.

CASE STORY NO. 2

Case was referred to Visiting Nurse Service of by EMIC, and the first visit was made in patient's eighth month of pregnancy. During this visit patient revealed to nurse that she had been married 3 months when her husband died of spinal meningitis.

Patient had planned to remain in the State of Washington with her husband until her baby was born, but upon his death she decided to return to New York to live with her family.

The patient also stated that she realized the added responsibility she had of caring for the baby in the absence of child's father and hoped that the child will receive the love and affection which would be missed from the father, from the male members of her own family.

During her pregnancy the patient had no complaints and felt confident that she would have a normal delivery.

On July 19, 1945, a 7-pound boby girl was born. The baby's left arm is normal to just below the wrist, but at this point small finger-like protrusions are present; but it is difficult to distinguish them as fingers. There is also a mild case of club feet. The mother is most appreciative of the excellent care which the baby has received in the hospital and the Visiting Nurse Service. The baby is to return to the hospital later for surgery.

Patient is greatly concerned over child's deformity but is anxious to provide the kind of care which will promote normal growth and development of child.

Patient does not appear bitter for all her adversities. She is especially grateful to EMIC for arranging for medical expenses during her pregnancy, for the privilege of having a visiting nurse, and now for the medical and surgical care which the baby is to receive.

CASE STORY NO. 3

Mrs. Y. is a young mother of 24 years of age. She developed a slight postpartum psychosis for which she needed treatment. The psychosis was not so severe that she couldn't carry out the care of her premature baby if she received necessary instruction and supervision. The need for a demonstration bath was indicated when the visiting nurse found she only washed the child's hands and face. She learned to give this bath adequately. The formula making had to be explained and demonstrated as well as the correct position for feedings. Instruction of infection prevention was explained since the baby's life depended on this care up to and past his 3 months of life. The husband was pathetically disturbed over fact that wife was not the same as when they first wed and the baby's prematurity all came as an overburdening problem. A demonstration was given to the father re formula making, feeding, changing diapers, and he is able to help wife assume some of the responsibility.

The wife realizing that the nurse is on hand and available has achieved a certain amount of peace of mind. She gives adequate care to baby and is helping herself by feeling she is contributing something to her home life in a well-planned, intelligent routine as suggested by our service.

CASE STORY NO. 4

A grandmother who had had Visiting Nurse Service 20 years ago called our nurse to visit her daughter's twins. When our nurse visited, she found that one infant had a cleft palate and thrush and the mother was advised to feed him with a tube. Neither the equipment nor the treatment was explained to the mother on discharge from the hospital; hence there was a marked decrease in weight.

Our nurse taught the mother how to feed the infants and to safeguard the second baby from thrush. At the suggestion of our nurse, the baby with the cleft palate was finally readmitted to the hospital where his dietary was improved to the extent that surgical repair of the cleft palate can be planned for much sooner.

After the mother was first discharged from the hospital, she began to hemorrhage profusely. She was upset over the cleft palate and put to bed while most of the care of the babies was relegated to grandmother. Bed rest and more assurance in the care of the twins paid dividends. The mother was soon up and about taking care of her babies. Thus she was able to plan purposefully for the future needs of herself and babies.

CASE STORY NO. 5

Mary Ann F. is the first child of a young couple whose married life has been a constant struggle. Mrs. F. did not have any antepartum care before Mary Ann was born and when the child was a few days old she was transferred from the maternity hospital, where he mother was continued to a communicable disease hospital with a diagnosis of gonorrheal eye infection. The baby was in the hospital for 4 months and upon discharge the parents were told that the baby had scars on the cornea and was totally blind.

Mrs. F. refused to accept the situation. When the nurse visited for infant health supervision, she found that Mrs. F. was taking the baby from one doctor to another and from one hospital clinic to another, always with the hope she would be told that her child would eventually see. Mrs. F. then lost interest in the baby and the nurse had to visit frequently to encourage her to give the baby necessary care. The case was reported to the Bureau for the Blind and a social worker has visited the family in order to encourage the mother to prepare for the child's admission to the Perkins Institute for the Blind.

Mary Ann is now nearly 6 years old and ready to be admitted to the Perkins Institute. She is a well-developed child with a fair complexion and curly, light brown hair, inquisitive, active, and graceful in her movements. During the past 3 months the nurse has again visited the F. home frequently because she learned through the Bureau for the Blind that Mary Ann would not be admitted to the institute unless she was toilet-trained and could feed herself. Mrs. F., who has

had two children in the intervening years, did not have sufficient patience to teach the child to feed herself or to establish satisfactory toilet routines.

One of our nurses, who is particularly interested in children, has been successful in her efforts. The child can now feed herself quite easily, although slowly, and takes great pride in her ability to look out for herself. The mother is at last looking forward with interest to the child's entrance to the Perkins Institute and the whole situation seems more hopeful. The other two children are normal, Mr. and Mrs. F. having had treatments before Mrs. F.'s second pregnancy.

CASE STORY NO. 6

Baby DeZ., first child of a young Italian couple, was referred to us upon discharge from a maternity hospital when she was 12 days old. Mrs. DeZ. had had a breech presentation and the baby had a brachial injury. The father was in

the Army and the mother lived with her people. The nurse went in daily for a week and helped the mother with the bath and the handling of the baby. She found the mother very nervous and upset, very much ashamed of the baby, and worried about the husband's reaction to the baby's condition. The neighbors were all curious, coming and looking at the baby's arm and shaking their heads over the fact that the baby was not fat and healthy. The mother declared that she would never be willing to take the baby out and wished to hide the baby insofar as she could. The doctor was consulted and our orthopedic nurse, under his directions, began to visit twice a week to give the baby massage and exercise, teaching the mother simple exercises to carry out between visits. The baby is now 4 months old. The arm is free and doing well although there is still not complete motion. The mother's attitude has changed. She takes the baby out and seems proud of the baby's progress.

CASE STORY NO. 7

Mrs. C. is an elderly primipara who benefited from medical and nursing care received under the EMIC plan.

She returned home from the hospital at the same time that Mr. C. received his medical discharge from the Army and this added to her problem of adjustment.

Because of the small size of the mother's uterus, baby Kenneth was born with a hyperextension of the neck and placidity of the arms. The baby weighed 5% pounds at time of dismissal from hospital. Because of his immaturity, this baby was both a feeding and a handling problem. It was impossible to keep the baby on his back or take him out of his crib for any length of time before he would become cyanotic. Therefore, oil baths were prescribed by the doctor and had to be administered while the baby was in his bassinet. The baby reacted to oil and developed a skin condition which was treated with sulfa drug.

Because of Mrs. C.'s attendance at mothers' club during her antepartum period, she was able to handle this situation confidently after initial assistance from the visiting nurse was received. Because of the assistance received from the EMIC plan, Mrs. C. had financial security which enabled her to adjust emotionally and physically to this difficult situation.

CASE STORY NO. 8

Mrs. S., 26 years old, born in Texas and married to a 32-year-old Seabee, found herself following him all over the country after the war began. She had had two miscarriages by the time he was sent to Rhode Island, and when she found she was again pregnant, she was discouraged and depressed.

As usual, on her travels, Mrs. S. took a furnished apartment so that her husband would have a place to stay on his off-duty time. The apartment house was full of servicemen's wives and one of them told the nurse about Mrs. S. and her troubles. In Rhode Island the Navy provides excellent clinic and hospital facilities for maternity care and the nurse persuaded Mrs. S. to place herself under the care of the Navy clinic physician. She admitted Mrs. S. as an antepartum patient and promised to visit her again.

A few days after Mrs. S. first attended the clinic the nurse had a call saying that Mrs. S. had started to bleed and was sure she would miscarry. The Navy doctor was called and said Mrs. S. should be hospitalized. This she refused. The next best thing, the doctor said, was to keep her in bed and give her progestin intramuscularly three times a week.

In reading the record one is conscious that this lonely, freightened girl received more than injections of medicine from the nurses who visited her. She needed encouragement and kindness and she received them. The weather was hot so they gave her bedside care, alcohol rubs, even shampooed her hair. At the end of 5 weeks there was no bleeding and she was allowed up.

Two months after we first met Mrs. S. her husband was notified of another transfer, this time to California. Mrs. S. decided that she was well enough to go. The doctor advised against it but she was sure she could make it. She said she had relatives in Los Angeles and would stay there after the baby arrived. Recently we received a letter from Mrs. S., a copy of which is enclosed. We hope the baby arrives safely on or about November 21.

"Dear Nurses: I promised to let you know how I made out on my trip from Providence to this coast; you all were so nice to me and helped me so much during those few months when I had the threatened miscarriage.

"We made the trip in our car and drove some 3,600 miles be ore reaching here, and with no trouble at all. It was a beautiful trip and fun too, all the way. We took it slow and were 21⁄2 weeks coming, stopping 2 days each in New York, Benton Harbor, Mich., and Denver, Colo., for rest periods. The last 2 days were extremely warm, but otherwise we had nice weather. According to the doctor here I'm fine and the little one is coming along nicely. Of course we are glad and getting anxious as the time grows near (November 21). My husband is on duty already, and the housing problem is a little more acute, but we hope to be really settled soon, so I can prepare for our baby in style. I hope this reaches all the girls who visited me to let them know that I haven't forgotten any of them, and from the bottom of my heart thank each and everyone.

"Sincerely yours,

CASE STORY NO. 9

"V. S."

The X family moved to New York City from a poor and undeveloped area of the South 3 years ago. They are an Irish-American family who came here because living and working conditions gave promise of something better.

We met them 2 years ago after the birth of their fifth son and have been in frequently for minor illnesses and health education. The pallor and lack of energy typical of many an Irish and southern diet is strongly evident in the entire family. Clinical attention is available but the crowded clinic takes the mother out of the home the greater part of a day. Home responsibilities are pressing and the additional duties as superintendent of the house force her to neglect herself and the children.

Lanny, a pale-faced lad of 10 is apparently becoming overconscious of a malformed arm and hand. He had been getting along well in school but for some unexpressed reason runs out of school or does not go to school and finds some necessary seclusion sitting by the water front and dreaming. He wishes he were "back home running barefoot and feeding the chickens." Clinical attention is available for Lanny but first the family must be convinced.

CASE STORY NO. 10

The visiting nurse was greeted by the new mother with friendliness and a real sign of relief. It seemed her new baby girl was giving Mrs. X a few anxious days. The nurse sat down to talk to Mrs. X and she skillfully drew out the information that would help in the care of Baby Mary.

Mrs. X had had a difficult labor ending in a convulsion during delivery. At 41 years she was having her third child, and 17 years after the second. She was now out of practice, and found it difficult to adjust her routine to include the baby and manage her household. Mrs. X then discussed her daily routine in length with the nurse who was able to help with short cuts and timesaving procedures and most of all to strengthen the mother's self-confidence. It was disclosed that Mrs. X's oldest child had been severely burned in an explosion at work and was slowly recovering in a hospital. This explained Mrs. X's nervousness, fatigue, and some instability without considering the new arrival. Nurse examined the baby, who seemed to be getting an unusual start in life, for it had a convulsion soon after birth, and now had other setbacks; abnormal stools, pustules on sore buttock, constipation, vomiting of its formula, sore and tender gums, and a full-length cast on its right leg. Through subsequent visits the nurse obtained the diagnosis of right congenital club foot and spastic paralysis. She showed the mother how to care for the cast and

avoid break-down of the skin areas, to care for the sore buttock; also demonstrated formula preparation and feeding of the baby, and on the advice of the M. D. how to rub the baby's gums with a soothing preparation; also administer an enema. The nurse checked the baby's weight carefully and noted a consistent weight loss.

With the weight loss the baby's resistance seemed lower and Mary developed a high temperature, and was taken to the hospital on advice of M. D. for a thorough formula adjustment. The baby passed safely through a serious period, when it had another convulsion. Upon dismissal in 2 weeks Mary showed a real weight gain, but with the hot weather had a heat rash. The nurse visited Mrs. X and Mary again and discussed Soda-Bi-Carb baths and use of cornstarch on Mary's heat rash. Mary was steadily improving and no longer looked like the sickly youngster of a few months ago. Now Mrs. X and the nurse turned to other channels of child care and discussed health habits and food habits of the young baby, demonstrations of how to present a new food to Mary were made. And now nursing care visits were definitely reduced in number as Mrs. X felt competent to care for her baby with occasional check-up visits.

Mrs. X had never been able to pay the nurse for her care and advice and after discussing the financial situation, the nurse decided this mother and baby were entitled to free care. Mrs. X never failed to express her appreciation of the value of the nurse in helping her regain her own health and baby's and to maintain a happy organized home. With many hospital bills to pay for the family and several consultants for Mary, Mrs. X's financial state was certainly sparing. Yet she needed so much extra time and help that hospitals and M. D.'s couldn't give her that she felt her own recovery and baby's wouldn't have been successful without the invaluable aid of the visiting nurse.

CASE STORY NO. 11

The visiting nurse was asked to call at a home where the mother had recently returned after giving birth to a son. Besides the new baby there were three other children-aged 2, 4, and 5 years. The mother was not well but she did not feel she could leave the children again to go to clinic for the half day that would be necessary. The family was unable to afford a private doctor. The children were all in need of vaccinations and immunizations. These were, arranged for through the child health station. Plans for regular medical supervision were also made through this means. The 2-year-old child, however, requires medical care for some yet undiagnosed malady. Here again is the problem of traveling a great distance to a hospital and then waiting one's turn at clinic since private doctor and necessary tests and treatments cannot be obtained due to lack of finances.

With more hospital facilities or perhaps a visiting doctor service, with fees adjusted to family income, this family could attain and maintain maximum health for all its members.

CASE STORY NO. 12

A postpartum visit recently took me into the home of a young SpanishAmerican mother with her second baby. When she was told that I was the city nurse a happy expression spread over her face, and with a sign of relief she said, "I thought I was out here all alone without anyone to help me with my babies." She had come out to be with her husband, and in a few days after her arrival he was sent overseas. Another case of a corporal and his wife living in a one-room cabin which at one time was part of a garage. Both are very young. Mother and baby were brought from the hospital, but it was necessary for her to stay in bed for another week. They had no one to stay with them during the day. After some effort I was able to get a lady to go in each day and give them daily care. At present she is up and about. She still welcomes the weekly visit from the nurse. There are so many of these young mothers who need to be reassured that they are doing their best for their babies.

CASE STORY NO. 13

As one nurse was hurrying to complete immunization in a small school so as to be able to return before the sun thawed the mud too much for travel, two men on horseback came to her to see a woman who had ben in labor for some 15 hours. As neither horse had a saddle, the nurse drove to the nearest and only ranch in her district that had a telephone. She borrowed a horse, com